1639651409 NPI number — WYATT PALMER HINTON OTA

Table of content: WYATT PALMER HINTON OTA (NPI 1639651409)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639651409 NPI number — WYATT PALMER HINTON OTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HINTON
Provider First Name:
WYATT
Provider Middle Name:
PALMER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639651409
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
113 BUFFALO TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EARLY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76802-2522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-320-5196
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 SONG BIRD CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROWNWOOD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76801-6488
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-646-4750
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X , with the licence number:  209521 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)