Provider Demographics
NPI:1982613071
Name:WUTHNOW, TINA (PA)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:WUTHNOW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:316-689-9102
Practice Address - Street 1:720 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-8778
Practice Address - Country:US
Practice Address - Phone:316-284-5115
Practice Address - Fax:316-284-5110
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS00414363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS206484OtherHPK
KS042838OtherBCBS
KS11106492OtherMULTIPLAN
KS9686OtherPHS
KS10039401BMedicaid
KS042838Medicare ID - Type Unspecified
P29443Medicare UPIN