1356637805 NPI number — WINDY A WYATT DO

Table of content: WINDY A WYATT DO (NPI 1356637805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356637805 NPI number — WINDY A WYATT DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYATT
Provider First Name:
WINDY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1356637805
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 MARQUIS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREEPORT
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04032-6477
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-865-6131
Provider Business Mailing Address Fax Number:
207-865-9399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 MARQUIS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREEPORT
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04032-6477
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-865-6131
Provider Business Practice Location Address Fax Number:
207-865-9399
Provider Enumeration Date:
06/23/2011

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: 207R00000X , with the licence number:  Q2088 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: DO2838 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 345061102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1356637805 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 345061101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 379203YLP1 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 379203YLP2 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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