Provider Demographics
NPI:1619505872
Name:WEDEL, DEREK MASON
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:MASON
Last Name:WEDEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3429 N MILLER RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-4513
Mailing Address - Country:US
Mailing Address - Phone:913-220-1727
Mailing Address - Fax:
Practice Address - Street 1:520 S SANTA FE AVE STE 300
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-4190
Practice Address - Country:US
Practice Address - Phone:785-823-7470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-31
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KS04-47699207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program