Healthcare Provider Details

I. General information

NPI: 1558067983
Provider Name (Legal Business Name): GARY PFANENSTIEL REGISTERED NURSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 E KELLOGG DR
WICHITA KS
67218-1607
US

IV. Provider business mailing address

5500 E KELLOGG DR
WICHITA KS
67218-1607
US

V. Phone/Fax

Practice location:
  • Phone: 316-685-2221
  • Fax: 316-634-3097
Mailing address:
  • Phone: 316-685-2221
  • Fax: 316-634-3097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0800X
TaxonomyOrthopedic Registered Nurse
License Number134039
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: