Basic Information
| Provider Information | |||||||||
| NPI: | 1639280431 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WYATT CLINIC, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1411 E. AMARILLO BLVD. | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791075555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063541015 | ||||||||
| FaxNumber: | 8063517274 | ||||||||
| Practice Location | |||||||||
| Address1: | 1411 E AMARILLO BLVD | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791075555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063517200 | ||||||||
| FaxNumber: | 8063517274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 03/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | HURT | ||||||||
| AuthorizedOfficialFirstName: | CAROLYN | ||||||||
| AuthorizedOfficialMiddleName: | SUE | ||||||||
| AuthorizedOfficialTitleorPosition: | CPMSM, CPCS | ||||||||
| AuthorizedOfficialTelephone: | 8063558900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363LA2200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 168039901 | 05 | TX | MEDICAID |