Provider Demographics
NPI:1295020717
Name:WYATT, AMY L (DO)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:WYATT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:L
Other - Last Name:VANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:409 S 2ND ST
Mailing Address - Street 2:SUITE 2F
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:717-988-0000
Mailing Address - Fax:717-782-5716
Practice Address - Street 1:111 S FRONT ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17101-2010
Practice Address - Country:US
Practice Address - Phone:717-988-0000
Practice Address - Fax:717-782-5716
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS017330207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102990303Medicaid
PA379671Medicare PIN