Healthcare Provider Details

I. General information

NPI: 1629859731
Provider Name (Legal Business Name): PAUL WYATT II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2023
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20611 EUCLID AVE
EUCLID OH
44117-1521
US

IV. Provider business mailing address

1541 E 191ST ST
EUCLID OH
44117-1330
US

V. Phone/Fax

Practice location:
  • Phone: 216-859-2727
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: