MEDICARE: SAMUEL BRUCE AITCHISON PHYSICIAN ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	K15-02254	KS

General Provider Information

NPI Number	:	1750949368
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL BRUCE AITCHISON PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	700 W CENTRAL AVE
Second Line	:
City	:	EL DORADO
State	:	KS
Zip	:	67042-2184
Country	:	US
Telephone Number	:	316-452-5113
Fax Number	:	316-452-5694

Provider Business Practice Location Address
First Line	:	700 W CENTRAL AVE STE 206
Second Line	:
City	:	EL DORADO
State	:	KS
Zip	:	67042-2186
Country	:	US
Telephone Number	:	316-452-5113
Fax Number	:	316-452-5694

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2019
Last Update Date	:	01/13/2021

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