Healthcare Provider Details

I. General information

NPI: 1164074852
Provider Name (Legal Business Name): WYATT A MACHUPA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 E CHEYENNE MOUNTAIN BLVD
COLORADO SPRINGS CO
80906-3769
US

IV. Provider business mailing address

202 E CHEYENNE MOUNTAIN BLVD
COLORADO SPRINGS CO
80906-3769
US

V. Phone/Fax

Practice location:
  • Phone: 719-527-9331
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number0016393
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number0016393
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: