Provider Demographics
NPI:1811693443
Name:WYATT, SAMANTHA MARIE (PTA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:WYATT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W DOUGLAS AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-3002
Mailing Address - Country:US
Mailing Address - Phone:316-263-0003
Mailing Address - Fax:316-263-1241
Practice Address - Street 1:2243 S MERIDIAN AVE STE 105
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67213-1911
Practice Address - Country:US
Practice Address - Phone:316-942-5448
Practice Address - Fax:316-945-5694
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-03763225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant