Healthcare Provider Details

I. General information

NPI: 1548901168
Provider Name (Legal Business Name): KEVIN DAVID WOTRING
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 CHERRY ST STE 210
LEESPORT PA
19533-8503
US

IV. Provider business mailing address

60 CHERRY ST STE 210
LEESPORT PA
19533-8503
US

V. Phone/Fax

Practice location:
  • Phone: 833-822-5221
  • Fax: 833-932-1226
Mailing address:
  • Phone: 484-822-5221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC007284
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: