Basic Information
| Provider Information | |||||||||
| NPI: | 1457987166 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DANNER | ||||||||
| FirstName: | WYATT | ||||||||
| MiddleName: | HAYDEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 92 | ||||||||
| Address2: | |||||||||
| City: | DRAYTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293330092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282263784 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3660 VISTA AVE STE 312 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145778000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2020 | ||||||||
| LastUpdateDate: | 03/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.