Healthcare Provider Details

I. General information

NPI: 1366522815
Provider Name (Legal Business Name): JASON P WILTSHIRE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 CLEVELAND ST MEDICAL PAVILION
GREAT BEND KS
67530-3562
US

IV. Provider business mailing address

514 CLEVELAND ST MEDICAL PAVILION
GREAT BEND KS
67530-3562
US

V. Phone/Fax

Practice location:
  • Phone: 620-792-2151
  • Fax: 620-860-0305
Mailing address:
  • Phone: 620-792-2151
  • Fax: 620-860-0305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number04-33922
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: