Provider Demographics
NPI:1275769010
Name:EWERTZ, KRISTIN DIANE (DPT)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:DIANE
Last Name:EWERTZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13303 W MAPLE ST
Mailing Address - Street 2:STE 129
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67235-8757
Mailing Address - Country:US
Mailing Address - Phone:316-854-5859
Mailing Address - Fax:316-854-5860
Practice Address - Street 1:13303 W MAPLE ST
Practice Address - Street 2:STE 129
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67235-8757
Practice Address - Country:US
Practice Address - Phone:316-854-5859
Practice Address - Fax:316-854-5860
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03953225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA2463001Medicare PIN
KSKA2463Medicare PIN