Healthcare Provider Details

I. General information

NPI: 1134415466
Provider Name (Legal Business Name): ANDRA L MIES COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2011
Last Update Date: 09/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 N MAIN STREET
WICHITA KS
67203-3601
US

IV. Provider business mailing address

610 N MAIN ST
WICHITA KS
67203-3618
US

V. Phone/Fax

Practice location:
  • Phone: 316-440-1600
  • Fax: 316-440-1675
Mailing address:
  • Phone: 316-440-1600
  • Fax: 316-440-1675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224ZL0004X
TaxonomyLow Vision Occupational Therapy Assistant
License Number18-00764
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: