Provider Demographics
NPI:1114291648
Name:WYATT, PHILLIP (RPT)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:WYATT
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 1:310 BAYOU RIDGE LOOP
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:AR
Mailing Address - Zip Code:72837-8475
Mailing Address - Country:US
Mailing Address - Phone:479-264-1669
Mailing Address - Fax:800-661-8025
Practice Address - Street 1:8952 MARKET ST
Practice Address - Street 2:SUITE 7B
Practice Address - City:DOVER
Practice Address - State:AR
Practice Address - Zip Code:72837-9110
Practice Address - Country:US
Practice Address - Phone:479-331-3303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT1789225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist