Provider Demographics
NPI:1104365055
Name:WOOTTEN, SAMUEL WESLEY
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:WESLEY
Last Name:WOOTTEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 DOREEN DR
Mailing Address - Street 2:
Mailing Address - City:HUMMELSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17036-2724
Mailing Address - Country:US
Mailing Address - Phone:717-566-4525
Mailing Address - Fax:
Practice Address - Street 1:126 DOREEN DR
Practice Address - Street 2:
Practice Address - City:HUMMELSTOWN
Practice Address - State:PA
Practice Address - Zip Code:17036-2724
Practice Address - Country:US
Practice Address - Phone:717-566-4525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer