Provider Demographics
NPI:1417000753
Name:BANKS, WYATT D (PT)
Entity Type:Individual
Prefix:MR
First Name:WYATT
Middle Name:D
Last Name:BANKS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:UT
Mailing Address - Zip Code:84725-0549
Mailing Address - Country:US
Mailing Address - Phone:435-878-2722
Mailing Address - Fax:435-878-2723
Practice Address - Street 1:660 E MAIN ST BLDG B
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:UT
Practice Address - Zip Code:84725-0549
Practice Address - Country:US
Practice Address - Phone:435-878-2722
Practice Address - Fax:435-878-2723
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0652225100000X
UT3082713-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV003402130Medicaid
NV003402130Medicaid