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General NPI Number Information
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NPI Number | 1194355719
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Entity Type | Individual
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Provider Name | MARLYN BRIAN WYATT DPT, RN
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Gender | Male
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Dates
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Enumeration Date | 01/23/2020
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Last Update Date | 04/16/2021
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Provider Practice Location Address
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Address Line | 845 SULLIVAN AVE
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City | FARMINGTON
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State | NM
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Zip | 87401-7356
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Country | US
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Telephone | 505-278-8295
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Fax | 505-436-2077
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Provider Business Mailing Address
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Address Line | 845 SULLIVAN AVE
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City | FARMINGTON
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State | NM
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Zip | 87401-7356
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Country | US
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Telephone | 505-278-8295
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Fax | 505-436-2077
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT5774
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License Number State | NM
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