Provider Demographics
NPI:1285016394
Name:EDDY, WYATT RANDOLPH (MS, MMS, PA-C)
Entity Type:Individual
Prefix:MR
First Name:WYATT
Middle Name:RANDOLPH
Last Name:EDDY
Suffix:
Gender:M
Credentials:MS, MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3269 N STOCKTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3619
Mailing Address - Country:US
Mailing Address - Phone:928-757-2101
Mailing Address - Fax:
Practice Address - Street 1:3269 STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3619
Practice Address - Country:US
Practice Address - Phone:928-757-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6055363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ033429Medicaid