Provider Demographics
NPI:1922554435
Name:MCCRACKIN, WYATT JOSEPH
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:JOSEPH
Last Name:MCCRACKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 HIGHWAY 308
Mailing Address - Street 2:
Mailing Address - City:GALIVANTS FERRY
Mailing Address - State:SC
Mailing Address - Zip Code:29544-7317
Mailing Address - Country:US
Mailing Address - Phone:843-358-8794
Mailing Address - Fax:
Practice Address - Street 1:3501 HIGHWAY 308
Practice Address - Street 2:
Practice Address - City:GALIVANTS FERRY
Practice Address - State:SC
Practice Address - Zip Code:29544-7317
Practice Address - Country:US
Practice Address - Phone:843-358-8794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer