Provider Demographics
NPI:1144321902
Name:PAXTON, MALISSA KAY (RPAC)
Entity type:Individual
Prefix:MRS
First Name:MALISSA
Middle Name:KAY
Last Name:PAXTON
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 PARKWOOD CT
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-8897
Mailing Address - Country:US
Mailing Address - Phone:316-789-0240
Mailing Address - Fax:
Practice Address - Street 1:606 MULBERRY RD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-3532
Practice Address - Country:US
Practice Address - Phone:316-788-3787
Practice Address - Fax:316-788-6930
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00798363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS15-00798OtherKS ST BOARD LICENSE
KSP00099501OtherRAILROAD MEDICARE
KS15-00798OtherKS ST BOARD LICENSE
KS1303200001Medicare NSC