MEDICARE: DR. RYAN WYATT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	S0408	TX
2	207P00000X	Emergency Medicine Physician	S0408	TX

General Provider Information

NPI Number	:	1134650062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RYAN WYATT M.D.

Provider Business Mailing Address
First Line	:	PO BOX 467
Second Line	:
City	:	HICO
State	:	TX
Zip	:	76457-0467
Country	:	US
Telephone Number	:	817-550-3898
Fax Number	:

Provider Business Practice Location Address
First Line	:	6451 BRENTWOOD STAIR RD STE 200
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-3200
Country	:	US
Telephone Number	:	817-496-9700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2017
Last Update Date	:	05/22/2026

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