Provider Demographics
NPI:1760597892
Name:CLINE, JENNY M (PA - C)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:M
Last Name:CLINE
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 1:10202 W 13TH ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-4377
Mailing Address - Country:US
Mailing Address - Phone:316-729-9100
Mailing Address - Fax:316-729-9185
Practice Address - Street 1:10202 W 13TH ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-4377
Practice Address - Country:US
Practice Address - Phone:316-729-9100
Practice Address - Fax:316-729-9185
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500706363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100355900BMedicaid
KS426779Medicare ID - Type UnspecifiedCLINIC PROVIDER BILLING #