Provider Demographics
NPI:1922086917
Name:JEWELL -BROUGHMAN, DANA GAYLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DANA
Middle Name:GAYLE
Last Name:JEWELL -BROUGHMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:DANA
Other - Middle Name:GAYLE
Other - Last Name:JEWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:210 W FIRST
Mailing Address - Street 2:
Mailing Address - City:SAINT FRANCIS
Mailing Address - State:KS
Mailing Address - Zip Code:67756
Mailing Address - Country:US
Mailing Address - Phone:785-332-2104
Mailing Address - Fax:785-332-3255
Practice Address - Street 1:210 W 1ST ST
Practice Address - Street 2:
Practice Address - City:SAINT FRANCIS
Practice Address - State:KS
Practice Address - Zip Code:67756-3540
Practice Address - Country:US
Practice Address - Phone:785-332-2104
Practice Address - Fax:785-332-3255
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500306363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100341330HMedicaid
KS427330OtherBCBS OF KANSAS
CO10882588Medicaid
427330OtherBCBS OF KANSAS
427330OtherBCBS OF KANSAS
KS110731013Medicare PIN