Healthcare Provider Details

I. General information

NPI: 1275147589
Provider Name (Legal Business Name): WYATT OSTRUM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5190 WILLIS RD
NORTH BRANCH MI
48461-8969
US

IV. Provider business mailing address

706 EMMET ST
YPSILANTI MI
48197-2971
US

V. Phone/Fax

Practice location:
  • Phone: 810-969-1197
  • Fax:
Mailing address:
  • Phone: 810-969-1197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: