Healthcare Provider Details

I. General information

NPI: 1053640151
Provider Name (Legal Business Name): ANGELA WYATT DERMATOLOGY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2009
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N VERDE ST SUITE 101
FLAGSTAFF AZ
86001-5256
US

IV. Provider business mailing address

150 N VERDE ST SUITE 101
FLAGSTAFF AZ
86001-5256
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 TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number42581
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number42581
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number42581
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number42581
License Number StateAZ
# 5
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number42581
License Number StateAZ

VIII. Authorized Official

Name: DR. ANGELA WYATT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 928-779-6923