Provider Demographics
NPI:1649844358
Name:WYATT, SUTHERLAND (DPT)
Entity type:Individual
Prefix:DR
First Name:SUTHERLAND
Middle Name:
Last Name:WYATT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 JEROME ST E
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6269
Mailing Address - Country:US
Mailing Address - Phone:530-514-9248
Mailing Address - Fax:
Practice Address - Street 1:754 N COLLEGE RD STE D
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5822
Practice Address - Country:US
Practice Address - Phone:208-734-5313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-7263225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1427029610Medicaid