Healthcare Provider Details

I. General information

NPI: 1265896203
Provider Name (Legal Business Name): AUTUMN LEIGH WYETH D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUTUMN ALLISON

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 W MARKHAM ST # 783
LITTLE ROCK AR
72205-7101
US

IV. Provider business mailing address

4301 W MARKHAM ST # 783
LITTLE ROCK AR
72205-7101
US

V. Phone/Fax

Practice location:
  • Phone: 501-686-8000
  • Fax: 501-526-5148
Mailing address:
  • Phone: 501-686-8000
  • Fax: 501-526-5148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberE-12805
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: