Provider Demographics
NPI:1780632794
Name:SMITH, WALYNN C (LPT)
Entity Type:Individual
Prefix:MR
First Name:WALYNN
Middle Name:C
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 CENTRAL AVE
Mailing Address - Street 2:SUITE #3
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-1376
Mailing Address - Country:US
Mailing Address - Phone:307-634-0298
Mailing Address - Fax:307-634-0837
Practice Address - Street 1:4000 CENTRAL AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1376
Practice Address - Country:US
Practice Address - Phone:307-634-0298
Practice Address - Fax:307-634-0837
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY160225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY20300Medicare ID - Type Unspecified