Healthcare Provider Details

I. General information

NPI: 1508319211
Provider Name (Legal Business Name): DEVIN WYSS LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E COUNTY LINE RD
GREENWOOD IN
46143-1063
US

IV. Provider business mailing address

555 E COUNTY LINE RD
GREENWOOD IN
46143-1063
US

V. Phone/Fax

Practice location:
  • Phone: 317-497-2130
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.004987
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: