Healthcare Provider Details

I. General information

NPI: 1982819199
Provider Name (Legal Business Name): PHILIP RICHARD WYATT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 OLD PECOS TRL
SANTA FE NM
87505-9025
US

IV. Provider business mailing address

3101 OLD PECOS TRL
SANTA FE NM
87505-9025
US

V. Phone/Fax

Practice location:
  • Phone: 505-438-2211
  • Fax: 505-438-2220
Mailing address:
  • Phone: 505-438-2211
  • Fax: 505-438-2220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170100000X
TaxonomyPh.D. Medical Genetics
License Number21374
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: