Tyler J Antenen, P.A.-C
Individual provider Active NPI Physician Assistant · Kingman, KS
NPI 1104377647 · NPPES record last updated Sep 3, 2025
Key facts
- NPI
- 1104377647
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Physician Assistant 363A00000X
- License
- 1501947 (KS)
- Practice address
- 750 W D Ave
Kingman, KS 67068-1266 - Phone
- (620) 532-0295
- Fax
- (855) 483-0002
- NPI assigned
- Oct 19, 2016
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 6
Hospital & facility affiliations 1
Medicare Care Compare profile
- Specialty
- Physician Assistant
- Education
- Other, 2016
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Ninnescah Valley Health Systems Inc
Practice addresses (Care Compare)
112 N Main St
Cunningham, KS 67035-8802
Phone (620) 298-2397
750 Ave D W
Kingman, KS 67068-1266
750 W D Ave
Kingman, KS 67068-1266
Phone (620) 532-3147
Hospital & facility affiliations
- Kingman Healthcare Center
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in KS
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20161118000114 | KS | Practitioner - Physician Assistant | 7113206988 | Reassigns benefits to 4 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1501947 | KS | MD | Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Ninnescah Valley Health Systems, Inc. | Current |
Accepting new patients | |
| Ninnescah Valley Health Systems Inc | Current | Accepting new patients | |
| Ninnescah Valley Health Systems, Inc. | Current | Accepting new patients | |
| Cancer Center of Kansas, P.a. | Past | Accepting new patients | |
| Ninnescah Valley Health Systems, Inc. | Past | Accepting new patients |
Locations
750 W D Ave
Kingman, KS 67068
Phone (620) 532-0295
Interoperability endpoints
- tyler.antenen.1@19447.direct.athenahealth.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 1501947 | KS | Yes |
Addresses
Primary practice location
750 W D Ave
Kingman, KS 67068-1266
Mailing address
750 W D Ave
Kingman, KS 67068-1266
Phone (620) 532-0295
Other practice location 1
112 N Main St
Cunningham, KS 67035-8802
Phone (620) 298-2397
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 20114690A | Medicaid | KS | |
| 30003916630006 | Medicaid | KS |
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Direct Messaging Address | tyler.antenen.1@19447.direct.athenahealth.com | Direct |
Other providers in Kingman, KS
- Advanced Mobile Healthcare and Community Clinic
- Alliance Imaging Inc
- Aspire Physical Therapy Inc
- Erin M Baxa
- Randall Renee Beech
- Laura C Bevis
- Jessica Blackwill
All providers in Kingman, KS · Physician Assistant in Kansas
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 3, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.