Provider Demographics
NPI:1124154992
Name:HEGSTROM, STEVE HAROLD (CPTA)
Entity type:Individual
Prefix:MR
First Name:STEVE
Middle Name:HAROLD
Last Name:HEGSTROM
Suffix:
Gender:M
Credentials:CPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5045 OUTLOOK RD
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66202-1842
Mailing Address - Country:US
Mailing Address - Phone:913-677-4806
Mailing Address - Fax:
Practice Address - Street 1:10300 W 103RD ST
Practice Address - Street 2:SUITE 300
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66214-2642
Practice Address - Country:US
Practice Address - Phone:913-941-1910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117642174400000X
KS14-00052174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS14-00052OtherSTATE LICENSE
MO117642OtherMISSOURI LICENSE