Basic Information
| Provider Information | |||||||||
| NPI: | 1326617937 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WYATT | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | DELBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1051 CURDES AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468052522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099108245 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10315 DAWSONS CREEK BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604367875 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2021 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0200X | 28246441A | IN | Y | Nursing Service Providers | Registered Nurse | Critical Care Medicine |
No ID Information.