Blue Valley Dermatology LLC

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

License

04-36968 Issued in KS

Legal business name

BLUE VALLEY DERMATOLOGY LLC

Practice address

7840 W 165TH Street
Suite 260
Overland Park, KS 66223

Phone

(415) 802-1310

NPI assigned

May 26, 2017

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Tom Tkachuk

Title

Manager

Phone

(415) 802-1310

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in KS

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Amber Evelyn Bischoff, PA-C

  • Physician Assistant
  • Overland Park, KS
  • NPI 1043723414
  Medicare reassignment Care Compare group NPD
• Allison Lisle Cargnel, MD

  • Anatomic Pathology & Clinical Pathology Physician
  • Overland Park, KS
  • NPI 1316054497
  Medicare reassignment Care Compare group NPD
• Whitney Blaire Fancher, M.D.

  • MOHS-Micrographic Surgery Physician
  • Overland Park, KS
  • NPI 1053699645

  Dermatology

  Medicare reassignment Care Compare group NPD
• Mitchell S Gibbons

  • Dermatology Physician
  • Overland Park, KS
  • NPI 1871116210
  Medicare reassignment Care Compare group NPD
• Lauren Ann Kyle Tkachuk, MD

  • Dermatology Physician
  • Overland Park, KS
  • NPI 1760709679
  Medicare reassignment Care Compare group NPD
• Bridget Stillwell

  • Nurse Practitioner
  • Prairie Village, KS
  • NPI 1699132522
  Medicare reassignment Care Compare group NPD
• Korey Ellen Walter, FNP

  • Family Nurse Practitioner
  • Overland Park, KS
  • NPI 1548157829
  Medicare reassignment Care Compare group NPD
• Taryne Dene Hensley, RN, MSN, APRN

  • Family Nurse Practitioner
  • Kansas City, MO
  • NPI 1871839910

  KS

  Medicare reassignment Care Compare group NPD
• Katherine Decker Parks

  • Family Nurse Practitioner
  • Rochester, NY
  • NPI 1629236302

  KS

  Medicare reassignment Care Compare group NPD
• Justin Dan Richey, M.D.

  • Dermatopathology (Pathology) Physician
  • Naples, FL
  • NPI 1639439086

  KS

  Medicare reassignment Care Compare group NPD
• Dana Faye Dickson, PA

  • Physician Assistant
  • Overland Park, KS
  • NPI 1285275149
  Medicare reassignment Care Compare group
• Vanessa N. Johnson, P.A.

  • Medical Physician Assistant
  • Kansas City, MO
  • NPI 1245474386

  KS

  Medicare reassignment Care Compare group

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1495756800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1635120000000",
    "number": "1104354794",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7840 W 165TH STREET",
            "address_2": "SUITE 260",
            "city": "OVERLAND PARK",
            "state": "KS",
            "postal_code": "66223",
            "telephone_number": "415-802-1310"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7840 W 165TH STREET",
            "address_2": "SUITE 260",
            "city": "OVERLAND PARK",
            "state": "KS",
            "postal_code": "66223",
            "telephone_number": "415-802-1310"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "7520 W 160th St Ste 100",
            "address_purpose": "LOCATION",
            "city": "Overland Park",
            "state": "KS",
            "postal_code": "660858137",
            "country_code": "US",
            "telephone_number": "913-871-8221",
            "fax_number": "913-495-5456",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "BLUE VALLEY DERMATOLOGY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-05-26",
        "last_updated": "2021-10-25",
        "certification_date": "2021-10-25",
        "status": "A",
        "authorized_official_last_name": "TKACHUK",
        "authorized_official_first_name": "TOM",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "415-802-1310"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": "KS",
            "license": "04-36968",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Dermatology Physician in Overland Park, KS
• Providers in Overland Park, KS by specialty
• Dermatology Physician in Kansas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 25, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.