MEDICARE: KELSEY PAIGE MENGWASSER PT, DPT

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	225100000X	Physical Therapist	PT-5761	ID

General Provider Information

NPI Number	:	1750877734
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY PAIGE MENGWASSER PT, DPT

Provider Business Mailing Address
First Line	:	810 MURPHYS WAY
Second Line	:
City	:	FARMINGTON
State	:	MO
Zip	:	63640-9241
Country	:	US
Telephone Number	:	573-220-5462
Fax Number	:

Provider Business Practice Location Address
First Line	:	2012 S JONES BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-3151
Country	:	US
Telephone Number	:	702-360-1137
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2018
Last Update Date	:	07/02/2018

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