MEDICARE: KATHY L WYANT 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	2085R0202X	Diagnostic Radiology Physician	13872	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497738629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHY L WYANT M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1387
Second Line	:	1125 N. PORTER, SUITE 100
City	:	NORMAN
State	:	OK
Zip	:	73070-1387
Country	:	US
Telephone Number	:	405-364-1071
Fax Number	:

Provider Business Practice Location Address
First Line	:	1125 N PORTER
Second Line	:	SUITE 100
City	:	NORMAN
State	:	OK
Zip	:	73071-6446
Country	:	US
Telephone Number	:	405-364-1071
Fax Number	:

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

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	02/03/2012

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