Provider Demographics
NPI:1417920661
Name:WYANT, THOMAS E JR (DC)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
Last Name:WYANT
Suffix:JR
Gender:M
Credentials:DC
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 181
Mailing Address - Street 2:
Mailing Address - City:MAPLETON
Mailing Address - State:IA
Mailing Address - Zip Code:51034-0181
Mailing Address - Country:US
Mailing Address - Phone:712-882-1977
Mailing Address - Fax:712-882-1977
Practice Address - Street 1:421 MAIN ST
Practice Address - Street 2:
Practice Address - City:MAPLETON
Practice Address - State:IA
Practice Address - Zip Code:51034-1212
Practice Address - Country:US
Practice Address - Phone:712-882-1977
Practice Address - Fax:712-882-1977
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2013-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA05786111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2110205Medicaid
IA2110205Medicaid