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General NPI Number Information
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NPI Number | 1598581365
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Entity Type | Individual
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Provider Name | WYATT AUSTIN ORTEGO IDC
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Gender | Male
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Dates
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Enumeration Date | 11/26/2024
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Last Update Date | 11/26/2024
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Provider Practice Location Address
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Address Line | 34101 FARENHOLT AVE BLDG 14
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City | SAN DIEGO
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State | CA
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Zip | 92134-7000
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Country | US
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Telephone | 619-532-7968
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Fax |
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Provider Business Mailing Address
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Address Line | 7025 WAITE DR APT 20A
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City | LA MESA
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State | CA
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Zip | 91941-7563
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Country | US
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Telephone | 417-440-0494
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1710I1002X
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Taxonomy Name | Independent Duty Corpsman
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License Number |
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License Number State |
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