Healthcare Provider Details

I. General information

NPI: 1790788511
Provider Name (Legal Business Name): DENNIS L SEWELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 HIGHLAND DRIVE
CONCORDIA KS
66901
US

IV. Provider business mailing address

1100 HIGHLAND DRIVE
CONCORDIA KS
66901
US

V. Phone/Fax

Practice location:
  • Phone: 785-243-1234
  • Fax: 785-243-8411
Mailing address:
  • Phone: 785-243-1234
  • Fax: 785-243-8411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15-00691
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: