Provider Demographics
NPI:1326396565
Name:AGAN, JAMIE L (PA-C)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:AGAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 N WEBB RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3405
Mailing Address - Country:US
Mailing Address - Phone:316-612-4815
Mailing Address - Fax:
Practice Address - Street 1:1921 N WEBB RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3405
Practice Address - Country:US
Practice Address - Phone:316-612-4815
Practice Address - Fax:316-612-4825
Is Sole Proprietor?:No
Enumeration Date:2012-08-20
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01550363A00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS132639656Medicaid
KS132639656Medicaid