Healthcare Provider Details

I. General information

NPI: 1699713412
Provider Name (Legal Business Name): MICHELLE T WYATT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1056 GREEN ACRES RD # 102-385
EUGENE OR
97408-1505
US

IV. Provider business mailing address

1056 GREEN ACRES RD # 102-385
EUGENE OR
97408-1505
US

V. Phone/Fax

Practice location:
  • Phone: 541-515-6593
  • Fax: 351-207-3929
Mailing address:
  • Phone: 541-515-6593
  • Fax: 351-207-3929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD18696
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: