MEDICARE: MR. LANCE EVERETT WYATT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	G79180	CA

General Provider Information

NPI Number	:	1851409916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LANCE EVERETT WYATT M.D.

Provider Business Mailing Address
First Line	:	8631 W 3RD ST
Second Line	:	STE. 1130 EAST TOWER
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-5901
Country	:	US
Telephone Number	:	310-855-8010
Fax Number	:	310-855-8015

Provider Business Practice Location Address
First Line	:	8631 W 3RD ST
Second Line	:	STE. 1130 EAST TOWER
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-5901
Country	:	US
Telephone Number	:	310-855-8010
Fax Number	:	310-855-8015

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	07/08/2007

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