Provider Demographics
NPI:1154857084
Name:KASSERMAN, WYATT (PT, DPT)
Entity Type:Individual
Prefix:
First Name:WYATT
Middle Name:
Last Name:KASSERMAN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 ROUTE 202
Mailing Address - Street 2:
Mailing Address - City:RARITAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08869-1449
Mailing Address - Country:US
Mailing Address - Phone:908-725-1144
Mailing Address - Fax:
Practice Address - Street 1:903 ROUTE 202
Practice Address - Street 2:
Practice Address - City:RARITAN
Practice Address - State:NJ
Practice Address - Zip Code:08869-1449
Practice Address - Country:US
Practice Address - Phone:908-725-1144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QAO1725900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist