Provider Demographics
NPI:1013952134
Name:PATTON, TREVER L (PHD)
Entity Type:Individual
Prefix:
First Name:TREVER
Middle Name:L
Last Name:PATTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7807 E FUNSTON ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207-3123
Mailing Address - Country:US
Mailing Address - Phone:316-636-1188
Mailing Address - Fax:316-636-1190
Practice Address - Street 1:7807 E FUNSTON ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-3123
Practice Address - Country:US
Practice Address - Phone:316-636-1188
Practice Address - Fax:316-636-1190
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1234103T00000X
IDPSY-202376103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID16849372OtherMEDICARE GROUP PIN
IDN6300OtherBLUE CROSS
ID1684937Medicare PIN
KSP99762Medicare UPIN
KS119804Medicare ID - Type UnspecifiedMEDICARE
ID16849371Medicare PIN