Healthcare Provider Details

I. General information

NPI: 1184543381
Provider Name (Legal Business Name): WYATT SAMUEL THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 SE PRAIRIE PARK LN
WAUKEE IA
50263-8412
US

IV. Provider business mailing address

670 SE PRAIRIE PARK LN
WAUKEE IA
50263-8412
US

V. Phone/Fax

Practice location:
  • Phone: 515-393-7347
  • Fax:
Mailing address:
  • Phone: 515-393-7347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: