Basic Information
| Provider Information | |||||||||
| NPI: | 1871563965 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WYATT | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635 | ||||||||
| Address2: | |||||||||
| City: | BELLMAWR | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080990635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567705772 | ||||||||
| FaxNumber: | 8565662797 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 CHAPEL AVE W | ||||||||
| Address2: | KENNEDY MEMORIAL HOSPITAL-UMC | ||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080022048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564886560 | ||||||||
| FaxNumber: | 8564886546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | MB032175 | NJ | X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZC0500X | MB032175 | NJ | X | Allopathic & Osteopathic Physicians | Pathology | Cytopathology |
ID Information
| ID | Type | State | Issuer | Description | 3856909 | 05 | NJ | MEDICAID |