Provider Demographics
NPI:1992731525
Name:GADDIS, MARK F (RPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:F
Last Name:GADDIS
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2146 N COLLECTIVE LN STE 114
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3574
Mailing Address - Country:US
Mailing Address - Phone:316-358-9942
Mailing Address - Fax:
Practice Address - Street 1:2146 N COLLECTIVE LN STE 114
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3574
Practice Address - Country:US
Practice Address - Phone:316-358-9942
Practice Address - Fax:316-358-0458
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1102957225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200270140BMedicaid
KSQ63558Medicare UPIN