Provider Demographics
NPI:1306636964
Name:WADDELL, WYATT (PTA)
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:
Last Name:WADDELL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8720 HORSESHOE LOOP
Mailing Address - Street 2:
Mailing Address - City:HACKETT
Mailing Address - State:AR
Mailing Address - Zip Code:72937-5537
Mailing Address - Country:US
Mailing Address - Phone:918-208-4976
Mailing Address - Fax:
Practice Address - Street 1:3304 S M ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2903
Practice Address - Country:US
Practice Address - Phone:479-785-4677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant