Provider Demographics
NPI:1780062612
Name:WEDEL, NICHOLAS DEAN (DPT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:DEAN
Last Name:WEDEL
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 1:2401 GILLHAM RD
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-4619
Mailing Address - Country:US
Mailing Address - Phone:816-701-5200
Mailing Address - Fax:816-302-9939
Practice Address - Street 1:1801 N 98TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66111
Practice Address - Country:US
Practice Address - Phone:913-264-3000
Practice Address - Fax:913-264-9940
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO225100000X
KS11-05141225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist