Provider Demographics
NPI:1912989138
Name:WICKS, DANE K (MD)
Entity type:Individual
Prefix:
First Name:DANE
Middle Name:K
Last Name:WICKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 SW MARION LN
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64081-2315
Mailing Address - Country:US
Mailing Address - Phone:505-977-5695
Mailing Address - Fax:816-600-2169
Practice Address - Street 1:4251 NORTHERN AVE
Practice Address - Street 2:HONOR ANNEX KANSAS CITY VA
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64133
Practice Address - Country:US
Practice Address - Phone:816-922-2870
Practice Address - Fax:816-922-4823
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4C66207Q00000X
NM84-288207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM34025Medicaid
A13629Medicare UPIN
NM34025Medicaid
343624101Medicare PIN
MOA13629Medicare UPIN