1164880563 NPI number — KAYLA M WYATT PA-C

Table of content: KAYLA M WYATT PA-C (NPI 1164880563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164880563 NPI number — KAYLA M WYATT PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYATT
Provider First Name:
KAYLA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

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:
1164880563
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1823 COLLEGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANHATTAN
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66502-3381
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-776-3322
Provider Business Mailing Address Fax Number:
785-565-4703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1823 COLLEGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANHATTAN
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66502-3381
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-776-3322
Provider Business Practice Location Address Fax Number:
785-565-4703
Provider Enumeration Date:
02/01/2016

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: 363A00000X , with the licence number:  15-01878 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 130520029 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".




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