Provider Demographics
NPI:1326305004
Name:WYATT, ROGER (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:WYATT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-7100
Mailing Address - Fax:208-302-7155
Practice Address - Street 1:315 E ELM ST
Practice Address - Street 2:STE 100
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605
Practice Address - Country:US
Practice Address - Phone:208-302-7100
Practice Address - Fax:208-302-7155
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR73187207Q00000X
IDM-12951207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine