Healthcare Provider Details

I. General information

NPI: 1992153670
Provider Name (Legal Business Name): WYATT MALOY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 PINION DR
USAF ACADEMY CO
80840-2502
US

IV. Provider business mailing address

4700 LAS VEGAS BLVD N
NELLIS AFB NV
89191-6600
US

V. Phone/Fax

Practice location:
  • Phone: 719-333-5187
  • Fax:
Mailing address:
  • Phone: 301-580-0055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number30439
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: