Healthcare Provider Details

I. General information

NPI: 1699537589
Provider Name (Legal Business Name): SETH WYNVEEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2024
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 NW MURRAY RD
LEES SUMMIT MO
64081-1455
US

IV. Provider business mailing address

7601 E 134TH TER
GRANDVIEW MO
64030-3427
US

V. Phone/Fax

Practice location:
  • Phone: 816-347-2738
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2018020984
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: