Healthcare Provider Details

I. General information

NPI: 1508205154
Provider Name (Legal Business Name): JESSE RYAN WYATT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2013
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HILLMONT AVE
VENTURA CA
93003
US

IV. Provider business mailing address

11234 ANDERSON ST GME OFFICE WESTERLY SUITE 'C'
LOMA LINDA CA
92354-2804
US

V. Phone/Fax

Practice location:
  • Phone: 805-652-6000
  • Fax:
Mailing address:
  • Phone: 909-558-4174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA126356
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberA126356
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: