Healthcare Provider Details

I. General information

NPI: 1417920661
Provider Name (Legal Business Name): THOMAS E WYANT JR. DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 02/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 MAIN ST
MAPLETON IA
51034-1212
US

IV. Provider business mailing address

PO BOX 181
MAPLETON IA
51034-0181
US

V. Phone/Fax

Practice location:
  • Phone: 712-882-1977
  • Fax: 712-882-1977
Mailing address:
  • Phone: 712-882-1977
  • Fax: 712-882-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberA05786
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: