Provider Demographics
NPI:1942979232
Name:BRANCH, WILEY CLARK
Entity Type:Individual
Prefix:MR
First Name:WILEY
Middle Name:CLARK
Last Name:BRANCH
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 1:89 W CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:MS
Mailing Address - Zip Code:39063-3509
Mailing Address - Country:US
Mailing Address - Phone:662-417-3159
Mailing Address - Fax:
Practice Address - Street 1:89 W CEDAR ST
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:MS
Practice Address - Zip Code:39063-3509
Practice Address - Country:US
Practice Address - Phone:662-417-3159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer