Basic Information
| Provider Information | |||||||||
| NPI: | 1417261835 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLIAM J. WYATT MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2232 DELL RANGE BLVD | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820094941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076388987 | ||||||||
| FaxNumber: | 3076387829 | ||||||||
| Practice Location | |||||||||
| Address1: | 2232 DELL RANGE BLVD | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820094941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076388987 | ||||||||
| FaxNumber: | 3076387829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2010 | ||||||||
| LastUpdateDate: | 07/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | WYATT | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSCIAN | ||||||||
| AuthorizedOfficialTelephone: | 3076388987 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2082S0105X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | Surgery of the Hand |
ID Information
| ID | Type | State | Issuer | Description | W307807 | 01 | WY | PTAN | OTHER |