Healthcare Provider Details

I. General information

NPI: 1851409916
Provider Name (Legal Business Name): LANCE EVERETT WYATT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8631 W 3RD ST STE. 1130 EAST TOWER
LOS ANGELES CA
90048-5901
US

IV. Provider business mailing address

8631 W 3RD ST STE. 1130 EAST TOWER
LOS ANGELES CA
90048-5901
US

V. Phone/Fax

Practice location:
  • Phone: 310-855-8010
  • Fax: 310-855-8015
Mailing address:
  • Phone: 310-855-8010
  • Fax: 310-855-8015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberG79180
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: