Provider Demographics
NPI:1710910302
Name:SELLBERG, JAMIE H (PA)
Entity Type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:H
Last Name:SELLBERG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 47572
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-7572
Mailing Address - Country:US
Mailing Address - Phone:316-261-3130
Mailing Address - Fax:316-261-3275
Practice Address - Street 1:848 N SAINT FRANCIS ST
Practice Address - Street 2:STE 2945
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3800
Practice Address - Country:US
Practice Address - Phone:316-261-3130
Practice Address - Fax:316-261-3275
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00650363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100340620BMedicaid
KS110955002Medicare PIN