Provider Demographics
NPI:1063651628
Name:WYMAN, DAVID LEROY (PT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:LEROY
Last Name:WYMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:SD
Mailing Address - Zip Code:57274-1054
Mailing Address - Country:US
Mailing Address - Phone:605-345-3336
Mailing Address - Fax:605-345-2543
Practice Address - Street 1:1401 W 1ST ST
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:SD
Practice Address - Zip Code:57274-1054
Practice Address - Country:US
Practice Address - Phone:605-345-3336
Practice Address - Fax:605-345-2543
Is Sole Proprietor?:No
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0943225100000X
ND1094225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist