MEDICARE: MR. WYATT D BANKS PT

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	0652	NV
2	225100000X	Physical Therapist	3082713-2401	UT

General Provider Information

NPI Number	:	1417000753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WYATT D BANKS PT

Provider Business Mailing Address
First Line	:	PO BOX 549
Second Line	:
City	:	ENTERPRISE
State	:	UT
Zip	:	84725-0549
Country	:	US
Telephone Number	:	435-878-2722
Fax Number	:	435-878-2723

Provider Business Practice Location Address
First Line	:	660 E MAIN ST BLDG B
Second Line	:
City	:	ENTERPRISE
State	:	UT
Zip	:	84725-0549
Country	:	US
Telephone Number	:	435-878-2722
Fax Number	:	435-878-2723

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

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	01/23/2020

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Directions to “ MR. WYATT D BANKS PT” Practice Location

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