MEDICARE: MARLYN BRIAN WYATT DPT, RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT5774	NM

General Provider Information

NPI Number	:	1194355719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARLYN BRIAN WYATT DPT, RN

Provider Business Mailing Address
First Line	:	845 SULLIVAN AVE
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87401-7356
Country	:	US
Telephone Number	:	505-278-8295
Fax Number	:	505-436-2077

Provider Business Practice Location Address
First Line	:	845 SULLIVAN AVE
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87401-7356
Country	:	US
Telephone Number	:	505-278-8295
Fax Number	:	505-436-2077

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2020
Last Update Date	:	04/16/2021

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