MEDICARE: BRANDYN WYATT OD

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	152W00000X	Optometrist	4683ATI	OR

General Provider Information

NPI Number	:	1821773722
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDYN WYATT OD

Provider Business Mailing Address
First Line	:	90 MARKET ST STE 20
Second Line	:
City	:	LEBANON
State	:	OR
Zip	:	97355-2396
Country	:	US
Telephone Number	:	541-451-2020
Fax Number	:	541-451-1785

Provider Business Practice Location Address
First Line	:	90 MARKET ST STE 20
Second Line	:
City	:	LEBANON
State	:	OR
Zip	:	97355-2396
Country	:	US
Telephone Number	:	541-451-2020
Fax Number	:	541-451-1785

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

Provider Enumeration Date	:	06/19/2023
Last Update Date	:	06/19/2023

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