Provider Demographics
NPI:1831261106
Name:WYMER, RICHARD DANIEL (PT)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:DANIEL
Last Name:WYMER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4455 S PADRE ISLAND DR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-5101
Mailing Address - Country:US
Mailing Address - Phone:361-879-0920
Mailing Address - Fax:361-879-0940
Practice Address - Street 1:4455 S PADRE ISLAND DR
Practice Address - Street 2:SUITE 8
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-5101
Practice Address - Country:US
Practice Address - Phone:361-879-0920
Practice Address - Fax:361-879-0940
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1030773225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX108018602Medicaid
TX1030773OtherSTATE LICENSE NUMBER
TX10779438OtherCAQH PROVIDER NUMBER
TX659504OtherHMO BLUE PROVIDER NUMBER
TXB0028012Medicare UPIN
TX108018602Medicaid
TX659504OtherHMO BLUE PROVIDER NUMBER