Provider Demographics
NPI:1093852907
Name:FIESER, SCOTT BRADLEY (PT, CSCS)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:BRADLEY
Last Name:FIESER
Suffix:
Gender:M
Credentials:PT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W DOUGLAS AVE
Mailing Address - Street 2:STE 1040
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-3013
Mailing Address - Country:US
Mailing Address - Phone:316-263-0003
Mailing Address - Fax:316-263-1241
Practice Address - Street 1:2311 S KANSAS RD
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-9032
Practice Address - Country:US
Practice Address - Phone:316-283-7187
Practice Address - Fax:316-283-7189
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03446225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200269680BMedicaid
KS200269680BMedicaid