Provider Demographics
NPI:1346583754
Name:BLUE, WYATT (MS, LAT, ATC, CSCS)
Entity type:Individual
Prefix:MR
First Name:WYATT
Middle Name:
Last Name:BLUE
Suffix:
Gender:M
Credentials:MS, LAT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1732 MACKINNON AVE
Mailing Address - Street 2:
Mailing Address - City:CARDIFF BY THE SEA
Mailing Address - State:CA
Mailing Address - Zip Code:92007-1605
Mailing Address - Country:US
Mailing Address - Phone:603-812-6913
Mailing Address - Fax:
Practice Address - Street 1:1732 MACKINNON AVE
Practice Address - Street 2:
Practice Address - City:CARDIFF BY THE SEA
Practice Address - State:CA
Practice Address - Zip Code:92007-1605
Practice Address - Country:US
Practice Address - Phone:603-812-6913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-03
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0506246171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor