Provider Demographics
NPI:1225557382
Name:WYLIE, ADAM
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:WYLIE
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 1:208 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28012
Mailing Address - Country:US
Mailing Address - Phone:704-517-1008
Mailing Address - Fax:
Practice Address - Street 1:133 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702
Practice Address - Country:US
Practice Address - Phone:904-738-9469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-10
Last Update Date:2017-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer