Basic Information
| Provider Information | |||||||||
| NPI: | 1164880563 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WYATT | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1823 COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665023381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7857763322 | ||||||||
| FaxNumber: | 7855654703 | ||||||||
| Practice Location | |||||||||
| Address1: | 1823 COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665023381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7857763322 | ||||||||
| FaxNumber: | 7855654703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2016 | ||||||||
| LastUpdateDate: | 10/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 15-01878 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 130520029 | 01 | MEDICARE | OTHER |