Provider Demographics
NPI:1134407109
Name:VANNOVER, MICAH JEANNE (PA-C)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:JEANNE
Last Name:VANNOVER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICAH
Other - Middle Name:JEANNE
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5500 E KELLOGG DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-1607
Mailing Address - Country:US
Mailing Address - Phone:316-685-2221
Mailing Address - Fax:316-634-3078
Practice Address - Street 1:5500 E KELLOGG DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1607
Practice Address - Country:US
Practice Address - Phone:316-685-2221
Practice Address - Fax:316-634-3078
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01465363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant