Provider Demographics
NPI:1114681715
Name:WHEATON, REGINALD THOMAS (PTA)
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:THOMAS
Last Name:WHEATON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 S LAKEVIEW CT
Mailing Address - Street 2:
Mailing Address - City:GODDARD
Mailing Address - State:KS
Mailing Address - Zip Code:67052-9228
Mailing Address - Country:US
Mailing Address - Phone:316-252-0445
Mailing Address - Fax:
Practice Address - Street 1:12 S LAKEVIEW CT
Practice Address - Street 2:
Practice Address - City:GODDARD
Practice Address - State:KS
Practice Address - Zip Code:67052-9228
Practice Address - Country:US
Practice Address - Phone:316-252-0445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-29
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS14-01922OtherKANSAS STATE LICENSE