Provider Demographics
NPI:1316072317
Name:WOOTEN, DARYL C (ATC)
Entity type:Individual
Prefix:MR
First Name:DARYL
Middle Name:C
Last Name:WOOTEN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2522 LOS ALAMOS CT
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-1657
Mailing Address - Country:US
Mailing Address - Phone:505-522-4949
Mailing Address - Fax:505-527-9767
Practice Address - Street 1:1755 EL PASEO RD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-6011
Practice Address - Country:US
Practice Address - Phone:505-527-9409
Practice Address - Fax:505-527-9767
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer