Provider Demographics
NPI:1629390331
Name:CHAMBERS, MISTY R (PA-C)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:R
Last Name:CHAMBERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:R
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4930 OVERLAND DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-4132
Mailing Address - Country:US
Mailing Address - Phone:785-856-0708
Mailing Address - Fax:785-856-0709
Practice Address - Street 1:4930 OVERLAND DR
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-4132
Practice Address - Country:US
Practice Address - Phone:785-856-0708
Practice Address - Fax:785-856-0709
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1501369363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200686550AMedicaid
KS200686550AMedicaid