Healthcare Provider Details

I. General information

NPI: 1760079958
Provider Name (Legal Business Name): MICHAEL ALEXANDER WILSHUSEN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2020
Last Update Date: 05/27/2023
Certification Date: 05/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W BROADWAY BLVD STE 300
SEDALIA MO
65301-5708
US

IV. Provider business mailing address

1200 CORPORATE DR STE 400
HOOVER AL
35242-5424
US

V. Phone/Fax

Practice location:
  • Phone: 660-827-2942
  • Fax:
Mailing address:
  • Phone: 423-238-7217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2020025989
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2251C2600X
TaxonomyCardiopulmonary Physical Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2251E1200X
TaxonomyErgonomics Physical Therapist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code2251E1300X
TaxonomyClinical Electrophysiology Physical Therapist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code2251H1200X
TaxonomyHand Physical Therapist
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code2251H1300X
TaxonomyHuman Factors Physical Therapist
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number StateNULL
# 10
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: