Provider Demographics
NPI:1073511671
Name:WYRICK, DREW HAWLEY (MD)
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:HAWLEY
Last Name:WYRICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 132890
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75713-2890
Mailing Address - Country:US
Mailing Address - Phone:903-747-3910
Mailing Address - Fax:903-617-6662
Practice Address - Street 1:1310 CLINIC DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2119
Practice Address - Country:US
Practice Address - Phone:903-747-3910
Practice Address - Fax:903-617-6662
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7639207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G94295Medicare UPIN
TX284435YRC2Medicare PIN
TX031020893Medicaid