Healthcare Provider Details

I. General information

NPI: 1215967849
Provider Name (Legal Business Name): GINA M WESTHOFF PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GINA M. BAILEY PA

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3515 BROADWAY AVE
GREAT BEND KS
67530-3633
US

IV. Provider business mailing address

3515 BROADWAY AVE
GREAT BEND KS
67530-3633
US

V. Phone/Fax

Practice location:
  • Phone: 620-792-2511
  • Fax: 620-792-3767
Mailing address:
  • Phone: 620-792-2511
  • Fax: 620-792-3767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0425245
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15-00947
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: