Provider Demographics
NPI:1730566860
Name:WYATT, TEMPLA (PTA)
Entity type:Individual
Prefix:
First Name:TEMPLA
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4632 OLD POND DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-4704
Mailing Address - Country:US
Mailing Address - Phone:972-408-6103
Mailing Address - Fax:
Practice Address - Street 1:1350 E LOOKOUT DR
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-4106
Practice Address - Country:US
Practice Address - Phone:972-220-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2039766225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant