Provider Demographics
NPI:1972817088
Name:ANDERSON, MARLYSE L (PA)
Entity Type:Individual
Prefix:
First Name:MARLYSE
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 N WEBB RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-8110
Mailing Address - Country:US
Mailing Address - Phone:316-636-6100
Mailing Address - Fax:316-636-5813
Practice Address - Street 1:2626 N WEBB RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-8110
Practice Address - Country:US
Practice Address - Phone:316-636-6100
Practice Address - Fax:316-636-5813
Is Sole Proprietor?:No
Enumeration Date:2010-07-30
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1501347363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant