Provider Demographics
NPI:1598349037
Name:WOODWARD, WYATT AUSTIN FOSTER
Entity Type:Individual
Prefix:
First Name:WYATT
Middle Name:AUSTIN FOSTER
Last Name:WOODWARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23961 CALLE DE LA MAGDALENA STE 119
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3616
Mailing Address - Country:US
Mailing Address - Phone:949-837-5111
Mailing Address - Fax:
Practice Address - Street 1:23961 CALLE DE LA MAGDALENA STE 119
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3616
Practice Address - Country:US
Practice Address - Phone:949-837-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299785225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist