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General NPI Number Information
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NPI Number | 1619977295
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Entity Type | Organization
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Legal Business Name | WYRICK DERMATOLOGY ASSOCIATION
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Dates
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Enumeration Date | 07/26/2005
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Last Update Date | 04/09/2013
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Provider Practice Location Address
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Address Line | 3333 POTOMAC AVE
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City | TEXARKANA
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State | TX
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Zip | 75503-3513
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Country | US
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Telephone | 903-792-3787
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Fax | 903-792-0446
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Provider Business Mailing Address
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Address Line | 3333 POTOMAC AVE
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City | TEXARKANA
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State | TX
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Zip | 75503-3513
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Country | US
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Telephone | 903-792-3787
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Fax | 903-792-0446
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Authorized Official
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Title or Position | PRESIDENT
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Name | SCOTT W WYRICK
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Credential | M.D.
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Telephone | 903-792-3787
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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