Provider Demographics
NPI:1518719392
Name:DWYER, MARK KEVIN (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:KEVIN
Last Name:DWYER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12484 S HALLET ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-6087
Mailing Address - Country:US
Mailing Address - Phone:314-320-4893
Mailing Address - Fax:
Practice Address - Street 1:202 S ROGERS RD
Practice Address - Street 2:
Practice Address - City:LOUISBURG
Practice Address - State:KS
Practice Address - Zip Code:66053-4064
Practice Address - Country:US
Practice Address - Phone:314-320-4893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-01347225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist