Provider Demographics
NPI:1396099057
Name:FETHERSTON, AUBREY JORDAN (PA-C)
Entity type:Individual
Prefix:
First Name:AUBREY
Middle Name:JORDAN
Last Name:FETHERSTON
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 1:520 S SANTA FE AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401
Mailing Address - Country:US
Mailing Address - Phone:785-823-7470
Mailing Address - Fax:785-823-0506
Practice Address - Street 1:520 S SANTA FE AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401
Practice Address - Country:US
Practice Address - Phone:785-823-7470
Practice Address - Fax:785-823-0506
Is Sole Proprietor?:No
Enumeration Date:2012-11-02
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200971050BMedicaid