Healthcare Provider Details

I. General information

NPI: 1821573478
Provider Name (Legal Business Name): ANDREW DIECKMANN PT, DPT, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2018
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 S BROADWAY ST STE E
MOORE OK
73160-5302
US

IV. Provider business mailing address

14638 S KAW DR
OLATHE KS
66062-4867
US

V. Phone/Fax

Practice location:
  • Phone: 405-735-8777
  • Fax:
Mailing address:
  • Phone: 913-645-2348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number6231
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2019026347
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: