MEDICARE: ADVANCED WOUND THERAPY-WA, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1134087422
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED WOUND THERAPY-WA, PLLC

Provider Business Mailing Address
First Line	:	2488 E 81ST ST STE 2000
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74137-4224
Country	:	US
Telephone Number	:	918-592-9020
Fax Number	:

Provider Business Practice Location Address
First Line	:	12615 E MISSION AVE STE 303
Second Line	:
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99216-1047
Country	:	US
Telephone Number	:	918-592-9020
Fax Number	:

Authorized Official
Title or Position	:	CHIEF ADMINISTRATIVE OFFICER
Name	:	SCOTT DICKMAN
Credential	:
Telephone Number	:	918-592-9020

Provider Enumeration Date	:	01/14/2026
Last Update Date	:	01/14/2026

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