Provider Demographics
NPI:1821573478
Name:DIECKMANN, ANDREW (PT, DPT, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:DIECKMANN
Suffix:
Gender:M
Credentials:PT, DPT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14638 S KAW DR
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-4867
Mailing Address - Country:US
Mailing Address - Phone:913-645-2348
Mailing Address - Fax:
Practice Address - Street 1:1700 S BROADWAY ST STE E
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-5302
Practice Address - Country:US
Practice Address - Phone:405-735-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-30
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190263472255A2300X
OK62312251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer