Provider Demographics
NPI:1326781220
Name:BOOTHBY-SHOEMAKER, WYATT
Entity Type:Individual
Prefix:
First Name:WYATT
Middle Name:
Last Name:BOOTHBY-SHOEMAKER
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 1:36701 COUNTY ROAD 374
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-8320
Mailing Address - Country:US
Mailing Address - Phone:269-808-1265
Mailing Address - Fax:
Practice Address - Street 1:5333 MCAULEY DR RM 2115
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1097
Practice Address - Country:US
Practice Address - Phone:734-712-3971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program