Healthcare Provider Details

I. General information

NPI: 1346215951
Provider Name (Legal Business Name): JAY M HEDGER LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2006
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1923 N WEBB RD
WICHITA KS
67206-3405
US

IV. Provider business mailing address

732 S WESTVIEW CIR
ANDOVER KS
67002-9336
US

V. Phone/Fax

Practice location:
  • Phone: 316-262-4886
  • Fax: 316-262-4887
Mailing address:
  • Phone: 316-733-7352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number24-0041
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: