Healthcare Provider Details

I. General information

NPI: 1497740989
Provider Name (Legal Business Name): FRANK WILLIS WYANT JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 DR. MLK JR. AVE., NE
ALBUQUERQUE NM
87102
US

IV. Provider business mailing address

8801 HORIZON BLVD NE SUITE 360
ALBUQUERQUE NM
87113-1533
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-6575
  • Fax: 505-764-8796
Mailing address:
  • Phone: 505-828-4923
  • Fax: 505-213-0103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA-864-87
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: