Provider Demographics
NPI:1124129911
Name:PRICE, EDWIN LYSLE (RPAC)
Entity type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:LYSLE
Last Name:PRICE
Suffix:
Gender:M
Credentials:RPAC
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1725 TIARA PINES DR
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-3933
Mailing Address - Country:US
Mailing Address - Phone:316-788-5369
Mailing Address - Fax:
Practice Address - Street 1:606 MULBERRY RD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-3532
Practice Address - Country:US
Practice Address - Phone:316-788-3787
Practice Address - Fax:316-788-6930
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00248363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS15-00248OtherKS ST BOARD LICENSE
KSP00099501OtherRAILROAD MEDICARE
KSP00099501OtherRAILROAD MEDICARE
KS1303200001Medicare NSC