Provider Demographics
NPI:1699284802
Name:GREENE, WYATT EZARA (PT, DPT)
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:EZARA
Last Name:GREENE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 CIRCLE 75 PKWY SE STE 1400
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3067
Mailing Address - Country:US
Mailing Address - Phone:678-981-3543
Mailing Address - Fax:404-777-1311
Practice Address - Street 1:22556 AMENDOLA TER STE 150
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20148-2413
Practice Address - Country:US
Practice Address - Phone:571-465-9289
Practice Address - Fax:571-465-9297
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211504225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist