Provider Demographics
NPI:1740595453
Name:SWANSON, TIMOTHY R (DPT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:SWANSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12112 W KELLOGG ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67235-1100
Mailing Address - Country:US
Mailing Address - Phone:316-440-1100
Mailing Address - Fax:316-440-1089
Practice Address - Street 1:2311 S KANSAS RD
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-9032
Practice Address - Country:US
Practice Address - Phone:316-283-7187
Practice Address - Fax:316-283-7189
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1104160225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200684980BMedicaid
KSKA1295023Medicare PIN