Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251N0400X | Physical Therapist - Neurology | 0016393 | CO |
N | 2251X0800X | Physical Therapist - Orthopedic | 0016393 | CO |
NPI | 1164074852 |
---|---|
Provider Name | Wyatt A Machupa |
First Address | Colorado Springs, CO 80906-3769 |
Second Address | Colorado Springs, CO 80906-3769 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2019 |
Last Update Date | 12/07/2019 |