Provider Demographics
NPI:1174033997
Name:SHOWLEY, WYATT EDWARD
Entity Type:Individual
Prefix:
First Name:WYATT
Middle Name:EDWARD
Last Name:SHOWLEY
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 1:827 W 13TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46975-2502
Mailing Address - Country:US
Mailing Address - Phone:574-223-0346
Mailing Address - Fax:
Practice Address - Street 1:827 W 13TH ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:IN
Practice Address - Zip Code:46975-2502
Practice Address - Country:US
Practice Address - Phone:574-223-0346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-06
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004492A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation