Healthcare Provider Details

I. General information

NPI: 1093636169
Provider Name (Legal Business Name): WYATT ROSS PHIPPS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4144 REDDEN
PRYOR OK
74361-9191
US

IV. Provider business mailing address

29809 E 155TH ST S
COWETA OK
74429-6016
US

V. Phone/Fax

Practice location:
  • Phone: 918-825-6825
  • Fax:
Mailing address:
  • Phone: 918-849-2857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: