Basic Information
| Provider Information | |||||||||
| NPI: | 1497738629 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WYANT | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1387 | ||||||||
| Address2: | 1125 N. PORTER, SUITE 100 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730701387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053641071 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1125 N PORTER | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053641071 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 02/03/2012 | ||||||||
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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 | 2085R0202X | 13872 | OK | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 100124550A | 05 | OK | MEDICAID |