Provider Demographics
NPI:1699731034
Name:WITTMAN, REX L (PA)
Entity type:Individual
Prefix:MR
First Name:REX
Middle Name:L
Last Name:WITTMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:800 MEDICAL CENTER DRIVE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-3765
Mailing Address - Country:US
Mailing Address - Phone:316-283-9977
Mailing Address - Fax:316-283-0966
Practice Address - Street 1:215 S PINE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-3765
Practice Address - Country:US
Practice Address - Phone:316-283-9977
Practice Address - Fax:316-283-0966
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS15-00326363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS111178028OtherPTAN
KS970012263OtherRR MEDICARE
KS042442OtherTRICARE
KS042442OtherBLUE CROSS BLUE SHIELD
KS100287500CMedicaid
KS100287500CMedicaid
KS042442OtherBLUE CROSS BLUE SHIELD