Provider Demographics
NPI:1336652957
Name:WIKE, BRIAN LEWIS I (PT, DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:LEWIS
Last Name:WIKE
Suffix:I
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2293 E FISHER LN
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-1922
Mailing Address - Country:US
Mailing Address - Phone:702-449-7461
Mailing Address - Fax:
Practice Address - Street 1:1868 W 9800 S STE 200
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4713
Practice Address - Country:US
Practice Address - Phone:801-676-2210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9772893-24012251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic