Healthcare Provider Details

I. General information

NPI: 1013911916
Provider Name (Legal Business Name): WYATT D WOODARD MSN, FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 09/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N LEROUX ST STE B
FLAGSTAFF AZ
86001-4535
US

IV. Provider business mailing address

320 N LEROUX ST STE B
FLAGSTAFF AZ
86001-4535
US

V. Phone/Fax

Practice location:
  • Phone: 928-779-0361
  • Fax: 928-779-7143
Mailing address:
  • Phone: 928-779-0361
  • Fax: 928-779-7143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP1235
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP1235
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: