Provider Demographics
NPI:1619953809
Name:AVERY, BRENDA (PA)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:AVERY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1228 WESTLOOP PL
Mailing Address - Street 2:CFNB #147
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-2840
Mailing Address - Country:US
Mailing Address - Phone:814-237-8627
Mailing Address - Fax:814-238-0083
Practice Address - Street 1:1133 COLLEGE AVE
Practice Address - Street 2:BLDG E SUITE 140
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-2770
Practice Address - Country:US
Practice Address - Phone:785-539-2500
Practice Address - Fax:785-539-2225
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS100917363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS042107OtherBCBS OF KANSAS
KSQ04272Medicare UPIN
KS042107OtherBCBS OF KANSAS
KS042107Medicare ID - Type Unspecified