Basic Information
| Provider Information | |||||||||
| NPI: | 1639161052 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WYER | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | LENAY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 617 | ||||||||
| Address2: | |||||||||
| City: | SOMERTON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853500617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2893157910 | ||||||||
| FaxNumber: | 9287226113 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 S OAK AVE | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853360756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2866204099 | ||||||||
| FaxNumber: | 9287226113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 45751 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP3257 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 443686 | 05 | AZ | MEDICAID |