Provider Demographics
NPI:1033162532
Name:WYATT, KRISTINE DANIELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:DANIELLE
Last Name:WYATT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 W 71ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74132-2011
Mailing Address - Country:US
Mailing Address - Phone:918-747-7799
Mailing Address - Fax:918-743-8648
Practice Address - Street 1:220 W 71ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74132-2011
Practice Address - Country:US
Practice Address - Phone:918-747-7799
Practice Address - Fax:918-743-8648
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA755363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical