Healthcare Provider Details

I. General information

NPI: 1588811756
Provider Name (Legal Business Name): CHARLES WELTON WYATT NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 W UNIVERSITY DR
PROSPER TX
75078-9805
US

IV. Provider business mailing address

PO BOX 733784
DALLAS TX
75373-3784
US

V. Phone/Fax

Practice location:
  • Phone: 682-303-4200
  • Fax: 682-303-4242
Mailing address:
  • Phone: 682-885-6483
  • Fax: 682-885-3113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP112728
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number655462
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP112728
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: