Provider Demographics
NPI:1295775138
Name:BORN, BOB (APRN)
Entity type:Individual
Prefix:
First Name:BOB
Middle Name:
Last Name:BORN
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 E 2ND ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4119
Mailing Address - Country:US
Mailing Address - Phone:316-303-0333
Mailing Address - Fax:316-847-7093
Practice Address - Street 1:1421 E 2ND ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4119
Practice Address - Country:US
Practice Address - Phone:316-303-0333
Practice Address - Fax:316-847-7093
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-78962-091163WP0808X
KS74595363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS160849OtherBLUE CROSS BLUE SHIELD
KS2144767OtherCIGNA
KS500029366OtherRAILROAD MEDICARE
KS14563OtherPREFERRED HEALTH SYSTEMS
KS160849OtherBLUE CROSS BLUE SHIELD
KS160849Medicare ID - Type Unspecified