MEDICARE: PHILLIP WYATT RPT

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	225100000X	Physical Therapist	PT1789	AR

General Provider Information

NPI Number	:	1114291648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLIP WYATT RPT

Provider Business Mailing Address
First Line	:	310 BAYOU RIDGE LOOP
Second Line	:
City	:	DOVER
State	:	AR
Zip	:	72837-8475
Country	:	US
Telephone Number	:	479-264-1669
Fax Number	:	800-661-8025

Provider Business Practice Location Address
First Line	:	8952 MARKET ST
Second Line	:	SUITE 7B
City	:	DOVER
State	:	AR
Zip	:	72837-9110
Country	:	US
Telephone Number	:	479-331-3303
Fax Number	:

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

Provider Enumeration Date	:	03/01/2012
Last Update Date	:	03/01/2012

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Directions to “ PHILLIP WYATT RPT” Practice Location

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