Healthcare Provider Details

I. General information

NPI: 1568518694
Provider Name (Legal Business Name): ROBERT CLYDE WYATT C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 MEDICAL CENTER DR
POCAHONTAS AR
72455-9436
US

IV. Provider business mailing address

1210 W COUNTRY CLUB TER
JONESBORO AR
72401-4374
US

V. Phone/Fax

Practice location:
  • Phone: 870-972-8053
  • Fax: 870-972-8053
Mailing address:
  • Phone: 870-972-1605
  • Fax: 870-972-8053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC00474 CRNA
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: