Healthcare Provider Details

I. General information

NPI: 1114291648
Provider Name (Legal Business Name): PHILLIP WYATT RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2012
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8952 MARKET ST SUITE 7B
DOVER AR
72837-9110
US

IV. Provider business mailing address

310 BAYOU RIDGE LOOP
DOVER AR
72837-8475
US

V. Phone/Fax

Practice location:
  • Phone: 479-331-3303
  • Fax:
Mailing address:
  • Phone: 479-264-1669
  • Fax: 800-661-8025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT1789
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: