Healthcare Provider Details

I. General information

NPI: 1477809226
Provider Name (Legal Business Name): AUSTIN ALAN ISHAM DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 11/12/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 1ST AVE NE #1
CEDAR RAPIDS IA
52402-4856
US

IV. Provider business mailing address

201 N 78TH ST
KANSAS CITY KS
66112
US

V. Phone/Fax

Practice location:
  • Phone: 319-398-6034
  • Fax:
Mailing address:
  • Phone: 913-226-9231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2012025073
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11-04469
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: