Provider Demographics
NPI:1669671483
Name:WYLIE, MICHAEL GORDON (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GORDON
Last Name:WYLIE
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 C ST
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:WA
Mailing Address - Zip Code:98230-4238
Mailing Address - Country:US
Mailing Address - Phone:360-332-8733
Mailing Address - Fax:
Practice Address - Street 1:456 C ST
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:WA
Practice Address - Zip Code:98230-4238
Practice Address - Country:US
Practice Address - Phone:360-332-8733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist