Provider Demographics
NPI:1790341121
Name:WYATT, GUNNAR
Entity Type:Individual
Prefix:
First Name:GUNNAR
Middle Name:
Last Name:WYATT
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 1:3038 REDBUD CIR
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50014-4518
Mailing Address - Country:US
Mailing Address - Phone:515-708-4940
Mailing Address - Fax:
Practice Address - Street 1:600 OAKMONT LN STE 600C
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-5548
Practice Address - Country:US
Practice Address - Phone:630-575-6250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-10
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist