Provider Demographics
NPI:1164880563
Name:WYATT, KAYLA M (PA-C)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:M
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 1:1823 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-3381
Mailing Address - Country:US
Mailing Address - Phone:785-776-3322
Mailing Address - Fax:785-565-4703
Practice Address - Street 1:1823 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-3381
Practice Address - Country:US
Practice Address - Phone:785-776-3322
Practice Address - Fax:785-565-4703
Is Sole Proprietor?:No
Enumeration Date:2016-02-01
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01878363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
130520029OtherMEDICARE