Healthcare Provider Details

I. General information

NPI: 1205031895
Provider Name (Legal Business Name): NATHANIEL WYNN LYTLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 JOHNSON FY RD NE STE 180
ATLANTA GA
30342-1795
US

IV. Provider business mailing address

1100 JOHNSON FY RD NE STE 180
ATLANTA GA
30342-1795
US

V. Phone/Fax

Practice location:
  • Phone: 404-250-6691
  • Fax: 404-250-8847
Mailing address:
  • Phone: 404-250-6691
  • Fax: 404-250-8847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number67501
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: