MEDICARE: MR. RONNIE WYATT PA

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	363A00000X	Physician Assistant	PA1709	FL

General Provider Information

NPI Number	:	1154399095
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RONNIE WYATT PA

Provider Business Mailing Address
First Line	:	841 STRATFORD DR
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813-4702
Country	:	US
Telephone Number	:	863-644-1255
Fax Number	:

Provider Business Practice Location Address
First Line	:	1417 LAKELAND HILLS BLVD
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33805-3200
Country	:	US
Telephone Number	:	863-682-8401
Fax Number	:	863-802-9611

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

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	07/08/2007

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