Provider Demographics
NPI:1215997861
Name:KIRK, NANCY L (PA-C)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:L
Last Name:KIRK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:LEE
Other - Last Name:RANDELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 764
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-0764
Mailing Address - Country:US
Mailing Address - Phone:316-268-8123
Mailing Address - Fax:316-291-7716
Practice Address - Street 1:8444 W 21ST ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1752
Practice Address - Country:US
Practice Address - Phone:316-721-9500
Practice Address - Fax:316-721-9574
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01070363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200354270AMedicaid
426922Medicare PIN
KS200354270AMedicaid
426921Medicare PIN
426920Medicare PIN