Healthcare Provider Details

I. General information

NPI: 1134038516
Provider Name (Legal Business Name): JONATHAN WIEMKEN ATC/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 VENTURE PARK DR
LAWRENCE KS
66046-5513
US

IV. Provider business mailing address

7300 STATE AVE APT 1-610
KANSAS CITY KS
66112-3016
US

V. Phone/Fax

Practice location:
  • Phone: 260-846-1068
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number24-01748
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: