Healthcare Provider Details

I. General information

NPI: 1285399170
Provider Name (Legal Business Name): MICHAEL WYKA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2021
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 FLANAGAN WAY
SECAUCUS NJ
07094-3445
US

IV. Provider business mailing address

576 BROADHOLLOW RD
MELVILLE NY
11747-5002
US

V. Phone/Fax

Practice location:
  • Phone: 201-992-0166
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA02045800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: