MEDICARE: WYATT JOHN TAYLOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1033982343
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WYATT JOHN TAYLOR

Provider Business Mailing Address
First Line	:	6628 CLEARWATER CREEK DR
Second Line	:
City	:	LINO LAKES
State	:	MN
Zip	:	55038-7705
Country	:	US
Telephone Number	:	612-222-8982
Fax Number	:

Provider Business Practice Location Address
First Line	:	6628 CLEARWATER CREEK DR
Second Line	:
City	:	LINO LAKES
State	:	MN
Zip	:	55038-7705
Country	:	US
Telephone Number	:	612-222-8982
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/30/2023
Last Update Date	:	10/30/2023

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