Provider Demographics
NPI:1659365823
Name:PERIDO, MILAGROS (PA C)
Entity Type:Individual
Prefix:MRS
First Name:MILAGROS
Middle Name:
Last Name:PERIDO
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 997
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:KS
Mailing Address - Zip Code:67950-0997
Mailing Address - Country:US
Mailing Address - Phone:620-697-2155
Mailing Address - Fax:620-697-4275
Practice Address - Street 1:411 SUNSET DR
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:KS
Practice Address - Zip Code:67950-0997
Practice Address - Country:US
Practice Address - Phone:620-697-2155
Practice Address - Fax:620-697-4275
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS123105363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS044465PEMedicare ID - Type Unspecified