Healthcare Provider Details

I. General information

NPI: 1134271125
Provider Name (Legal Business Name): JEFFERY DALE WYATT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W BOUNDARY AVE
WINNFIELD LA
71483-3427
US

IV. Provider business mailing address

345 A J WYATT LOOP RD
JONESBORO LA
71251-7503
US

V. Phone/Fax

Practice location:
  • Phone: 318-648-3072
  • Fax:
Mailing address:
  • Phone: 318-259-1242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN075781 APO4189
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: