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General NPI Number Information
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NPI Number | 1730507492
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Entity Type | Individual
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Provider Name | WILSON KEUNGKHAMPHONG COTA
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Gender | Male
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Dates
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Enumeration Date | 03/31/2014
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Last Update Date | 03/31/2014
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Provider Practice Location Address
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Address Line | 21513 W 50TH ST
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City | SHAWNEE
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State | KS
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Zip | 66226-9793
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Country | US
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Telephone | 913-207-9383
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Fax |
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Provider Business Mailing Address
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Address Line | 21513 W 50TH ST
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City | SHAWNEE
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State | KS
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Zip | 66226-9793
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Country | US
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Telephone | 913-207-9383
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 18-01030
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License Number State | KS
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