Provider Demographics
NPI:1639149784
Name:MEYERHOFF, MARK L (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:MEYERHOFF
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5500 E KELLOGG DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-1607
Mailing Address - Country:US
Mailing Address - Phone:316-685-2221
Mailing Address - Fax:316-681-5522
Practice Address - Street 1:5500 E KELLOGG DR
Practice Address - Street 2:SUITE 1
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1607
Practice Address - Country:US
Practice Address - Phone:316-685-2221
Practice Address - Fax:316-681-5522
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS15-00735363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100371870BMedicaid
KSP16402Medicare UPIN
KS100371870BMedicaid