Healthcare Provider Details

I. General information

NPI: 1528011368
Provider Name (Legal Business Name): ANGELA J WYATT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N VERDE ST STE 101
FLAGSTAFF AZ
86001-5257
US

IV. Provider business mailing address

1501 S YALE ST SUITE 152
FLAGSTAFF AZ
86001-7304
US

V. Phone/Fax

Practice location:
  • Phone: 928-779-6923
  • Fax: 928-779-6924
Mailing address:
  • Phone: 928-779-6923
  • Fax: 928-779-6924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number42581
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberM4667
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number226600
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number42581
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number226600
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberM4667
License Number StateTX
# 7
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number226600
License Number StateNY
# 8
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License NumberM4667
License Number StateTX
# 9
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number42581
License Number StateAZ
# 10
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number42581
License Number StateAZ
# 11
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number226600
License Number StateNY
# 12
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberM4667
License Number StateTX
# 13
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number42581
License Number StateAZ
# 14
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number226600
License Number StateNY
# 15
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberM4667
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: