Healthcare Provider Details

I. General information

NPI: 1629508965
Provider Name (Legal Business Name): WYATT ANDREW VERPLAETSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 02/09/2026
Certification Date: 02/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MAIN ST STE 200
PEORIA IL
61606-2035
US

IV. Provider business mailing address

1001 MAIN ST STE 200
PEORIA IL
61606-2035
US

V. Phone/Fax

Practice location:
  • Phone: 309-308-2010
  • Fax: 309-671-2167
Mailing address:
  • Phone: 309-308-2010
  • Fax: 309-671-2167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.071367
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number207K00000X
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number2022026074
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036155926
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: