1700312303 NPI number — ELIZABETH M WYRICK PT

Table of content: ELIZABETH M WYRICK PT (NPI 1700312303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700312303 NPI number — ELIZABETH M WYRICK PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYRICK
Provider First Name:
ELIZABETH
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NAPYCHANK
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700312303
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 RIVERSIDE ST
Provider Second Line Business Mailing Address:
SUITE 6B
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04103-1073
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-661-2093
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 SPRING ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SCARBOROUGH
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04074-8926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-396-7337
Provider Business Practice Location Address Fax Number:
207-885-4349
Provider Enumeration Date:
05/03/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT1321 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)