Provider Demographics
NPI:1750949368
Name:AITCHISON, SAMUEL BRUCE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:BRUCE
Last Name:AITCHISON
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:KS
Mailing Address - Zip Code:67042-2184
Mailing Address - Country:US
Mailing Address - Phone:316-452-5113
Mailing Address - Fax:316-452-5694
Practice Address - Street 1:700 W CENTRAL AVE STE 206
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042-2186
Practice Address - Country:US
Practice Address - Phone:316-452-5113
Practice Address - Fax:316-452-5694
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSK15-02254363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant