Healthcare Provider Details

I. General information

NPI: 1134650062
Provider Name (Legal Business Name): RYAN WYATT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 05/28/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6451 BRENTWOOD STAIR RD STE 200
FORT WORTH TX
76112-3200
US

IV. Provider business mailing address

PO BOX 467
HICO TX
76457-0467
US

V. Phone/Fax

Practice location:
  • Phone: 817-496-9700
  • Fax:
Mailing address:
  • Phone: 817-550-3898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberS0408
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: