Provider Demographics
NPI:1215967849
Name:WESTHOFF, GINA M (PA)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:WESTHOFF
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:M
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3515 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-3633
Mailing Address - Country:US
Mailing Address - Phone:620-792-2511
Mailing Address - Fax:620-792-3767
Practice Address - Street 1:3515 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3633
Practice Address - Country:US
Practice Address - Phone:620-792-2511
Practice Address - Fax:620-792-3767
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0425245363AM0700X
KS15-00947207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200300590AMedicaid
042053OtherBCBS
659930OtherFIRST GUARD
042053Medicare ID - Type Unspecified
KS003768041Medicare PIN
042053OtherBCBS