Provider Demographics
NPI:1558954396
Name:WICKERSHAM, MEGAN N (PTA)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:N
Last Name:WICKERSHAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4916 W 108TH TER APT 727
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1263
Mailing Address - Country:US
Mailing Address - Phone:417-496-4524
Mailing Address - Fax:
Practice Address - Street 1:20911 W 153RD ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-6219
Practice Address - Country:US
Practice Address - Phone:913-397-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-03823225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant