Healthcare Provider Details

I. General information

NPI: 1164455291
Provider Name (Legal Business Name): RHETT DAVID BOUZIDEN P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 KENTUCKY ST
ASHLAND KS
67831-3199
US

IV. Provider business mailing address

PO BOX 188
ASHLAND KS
67831-0188
US

V. Phone/Fax

Practice location:
  • Phone: 620-635-2241
  • Fax:
Mailing address:
  • Phone: 620-635-2241
  • Fax: 620-635-2229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1501058
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: