Provider Demographics
NPI:1083716153
Name:WYATT, CASI MCPHERSON (DO)
Entity Type:Individual
Prefix:
First Name:CASI
Middle Name:MCPHERSON
Last Name:WYATT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:CASI
Other - Middle Name:LYNN
Other - Last Name:MCPHERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:125 E IDAHO ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6212
Mailing Address - Country:US
Mailing Address - Phone:208-338-0148
Mailing Address - Fax:208-336-4027
Practice Address - Street 1:125 E IDAHO ST
Practice Address - Street 2:SUITE 203
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6212
Practice Address - Country:US
Practice Address - Phone:208-338-0148
Practice Address - Fax:208-336-4027
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3714207R00000X
IDO-0530207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA26705OtherWELLMARK BCBS
IA0731364Medicaid
IAI18420Medicare PIN
IAI62496Medicare UPIN