Provider Demographics
NPI:1497484554
Name:SANDER, WYATT ROBERT (PT, DPT)
Entity Type:Individual
Prefix:
First Name:WYATT
Middle Name:ROBERT
Last Name:SANDER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 NW OLYMPIC DR STE J
Mailing Address - Street 2:
Mailing Address - City:GRAIN VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64029-7865
Mailing Address - Country:US
Mailing Address - Phone:816-867-0066
Mailing Address - Fax:
Practice Address - Street 1:1460 NW OLYMPIC DR STE J
Practice Address - Street 2:
Practice Address - City:GRAIN VALLEY
Practice Address - State:MO
Practice Address - Zip Code:64029-7865
Practice Address - Country:US
Practice Address - Phone:816-867-0066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022018259225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist