Provider Demographics
NPI:1710954995
Name:GWYN, ERIN M (PA)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:M
Last Name:GWYN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:M
Other - Last Name:BROKSCHMIDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2778 N WEBB RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-8112
Mailing Address - Country:US
Mailing Address - Phone:316-631-1600
Mailing Address - Fax:316-631-1617
Practice Address - Street 1:2778 N WEBB RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-8112
Practice Address - Country:US
Practice Address - Phone:316-631-1600
Practice Address - Fax:316-631-1617
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00953363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200000510AMedicaid
P99320Medicare UPIN
KS200000510AMedicaid