Basic Information
| Provider Information | |||||||||
| NPI: | 1780008904 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST TEXAS WYATT CLINIC PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 367 S GULPH RD | ||||||||
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| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194063121 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1411 E AMARILLO BLVD | ||||||||
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| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791075555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063541015 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2014 | ||||||||
| LastUpdateDate: | 06/27/2019 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 6107683300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | DV2201 | 01 | TX | RR MEDICARE | OTHER | 3393704 01 | 05 | TX | MEDICAID |