Provider Demographics
NPI:1760582878
Name:BELL, JACK S (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:S
Last Name:BELL
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:226 SE DEBELL
Mailing Address - Street 2:BLDG A
Mailing Address - City:BARTTESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006
Mailing Address - Country:US
Mailing Address - Phone:620-251-5400
Mailing Address - Fax:620-251-5412
Practice Address - Street 1:1411 W 4TH
Practice Address - Street 2:SUITE G
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337
Practice Address - Country:US
Practice Address - Phone:620-251-5400
Practice Address - Fax:620-251-5412
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2011-06-14
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Provider Licenses
StateLicense IDTaxonomies
KS15-00239363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200334070AMedicaid
KS200334070AMedicaid