Provider Demographics
NPI:1306228341
Name:WASMUTH, TY
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:
Last Name:WASMUTH
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 1:24138 BLUE HERON DR
Mailing Address - Street 2:
Mailing Address - City:BRILLION
Mailing Address - State:WI
Mailing Address - Zip Code:54110-9316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24138 BLUE HERON DR
Practice Address - Street 2:
Practice Address - City:BRILLION
Practice Address - State:WI
Practice Address - Zip Code:54110-9316
Practice Address - Country:US
Practice Address - Phone:920-901-7843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIW25380592010082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer