Provider Demographics
NPI:1710925136
Name:WIESNER, DOUGLAS K (ATC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:K
Last Name:WIESNER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10701 NALL AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1363
Mailing Address - Country:US
Mailing Address - Phone:913-663-2555
Mailing Address - Fax:913-663-3766
Practice Address - Street 1:10777 NALL AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1362
Practice Address - Country:US
Practice Address - Phone:913-663-2555
Practice Address - Fax:913-312-1781
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-001512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer