Provider Demographics
NPI:1295626588
Name:RODERICK, WYATT
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:
Last Name:RODERICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 NW GILMAN BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2549
Mailing Address - Country:US
Mailing Address - Phone:206-605-8854
Mailing Address - Fax:
Practice Address - Street 1:160 NW GILMAN BLVD STE 310
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2549
Practice Address - Country:US
Practice Address - Phone:425-245-5540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIHS.FS.61601295253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care