Provider Demographics
NPI:1912518655
Name:WAKASA, KOTA (ATC)
Entity Type:Individual
Prefix:
First Name:KOTA
Middle Name:
Last Name:WAKASA
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 1:600 PARK ST
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-4099
Mailing Address - Country:US
Mailing Address - Phone:620-639-2733
Mailing Address - Fax:
Practice Address - Street 1:600 PARK ST
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-4099
Practice Address - Country:US
Practice Address - Phone:620-639-2733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-15
Last Update Date:2020-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer