Provider Demographics
NPI:1134868342
Name:HERMRECK, JASON D (PA)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:D
Last Name:HERMRECK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7550 W VILLAGE CIR STE 1
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-9364
Mailing Address - Country:US
Mailing Address - Phone:316-838-2020
Mailing Address - Fax:
Practice Address - Street 1:7550 W VILLAGE CIR STE 1
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-9364
Practice Address - Country:US
Practice Address - Phone:316-838-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-04
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS15-02897OtherKANSAS PHYSICIAN ASSISTANT LICENSE
KS3000513930001Medicaid