Provider Demographics
NPI:1437703634
Name:WOOD, GARRET WILLIAM (ATC)
Entity Type:Individual
Prefix:
First Name:GARRET
Middle Name:WILLIAM
Last Name:WOOD
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5932 DAVID ST
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2057
Mailing Address - Country:US
Mailing Address - Phone:208-850-6597
Mailing Address - Fax:
Practice Address - Street 1:5932 DAVID ST
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2057
Practice Address - Country:US
Practice Address - Phone:208-850-6597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-583207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA