Healthcare Provider Details

I. General information

NPI: 1245939826
Provider Name (Legal Business Name): ADAM DISETTE PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2023
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8550 MARSHALL DR STE 210
LENEXA KS
66214-9836
US

IV. Provider business mailing address

200 W DOUGLAS AVE STE 250
WICHITA KS
67202-3002
US

V. Phone/Fax

Practice location:
  • Phone: 913-492-0333
  • Fax:
Mailing address:
  • Phone: 316-263-0003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number14-04071
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: