MEDICARE: DANE K WICKS MD

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	R4C66	MO
2	207Q00000X	Family Medicine Physician	84-288	NM
3	207QG0300X	Geriatric Medicine (Family Medicine) Physician	84-288	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912989138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANE K WICKS MD

Provider Business Mailing Address
First Line	:	307 SW MARION LN
Second Line	:
City	:	LEES SUMMIT
State	:	MO
Zip	:	64081-2315
Country	:	US
Telephone Number	:	505-977-5695
Fax Number	:	816-600-2169

Provider Business Practice Location Address
First Line	:	4251 NORTHERN AVE
Second Line	:	HONOR ANNEX KANSAS CITY VA
City	:	KANSAS CITY
State	:	MO
Zip	:	64133
Country	:	US
Telephone Number	:	816-922-2870
Fax Number	:	816-922-4823

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

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	10/07/2016

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Directions to “ DANE K WICKS MD” Practice Location

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