Provider Demographics
NPI:1255305140
Name:WYATT-HARRIS, PATRICIA G (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:G
Last Name:WYATT-HARRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3233 E 2ND ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3202
Mailing Address - Country:US
Mailing Address - Phone:316-683-6766
Mailing Address - Fax:316-616-0073
Practice Address - Street 1:3233 E 2ND ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3202
Practice Address - Country:US
Practice Address - Phone:316-683-6766
Practice Address - Fax:316-616-0073
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS19715174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100169900AMedicaid
KS047339OtherBCBS ID #
KS1045OtherPPK ID #
KSB91252Medicare UPIN
KS1045OtherPPK ID #