Healthcare Provider Details

I. General information

NPI: 1134496193
Provider Name (Legal Business Name): WICHITA PAIN ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2011
Last Update Date: 12/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2548 N MAIZE CT SUITE 104
WICHITA KS
67205-7347
US

IV. Provider business mailing address

2544 N MAIZE CT SUITE 100
WICHITA KS
67205-7324
US

V. Phone/Fax

Practice location:
  • Phone: 316-722-4247
  • Fax: 316-722-4287
Mailing address:
  • Phone: 316-722-4247
  • Fax: 316-722-4287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number04-23263
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0424741
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0430440
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number44143
License Number StateKS

VIII. Authorized Official

Name: DR. JEFFREY DUANE FENN
Title or Position: PRESIDENT
Credential: D.C.
Phone: 316-258-5955