Provider Demographics
NPI:1609808955
Name:MATTKE, AMBER N (PA)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:N
Last Name:MATTKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 N HILLSIDE ST STE 510
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4928
Mailing Address - Country:US
Mailing Address - Phone:316-685-0559
Mailing Address - Fax:316-685-0455
Practice Address - Street 1:551 N HILLSIDE ST STE 510
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4928
Practice Address - Country:US
Practice Address - Phone:316-685-0559
Practice Address - Fax:316-685-0455
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01047363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSQ52298Medicare UPIN
KS200336990AMedicaid
KS426885Medicare ID - Type Unspecified