Provider Demographics
NPI:1861598088
Name:WICKWAR, WESLEY WILLIAM (PT FAAOMPT)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:WILLIAM
Last Name:WICKWAR
Suffix:
Gender:M
Credentials:PT FAAOMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 TYLER DR
Mailing Address - Street 2:
Mailing Address - City:HOLCOMB
Mailing Address - State:KS
Mailing Address - Zip Code:67851-9752
Mailing Address - Country:US
Mailing Address - Phone:620-277-0041
Mailing Address - Fax:
Practice Address - Street 1:1800 PALACE DIRVE
Practice Address - Street 2:SUITE C
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846
Practice Address - Country:US
Practice Address - Phone:620-271-0700
Practice Address - Fax:620-271-0703
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11032452251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS117012Medicare PIN