Provider Demographics
NPI:1356637805
Name:WYATT, WINDY A (DO)
Entity Type:Individual
Prefix:
First Name:WINDY
Middle Name:A
Last Name:WYATT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 MARQUIS RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-6477
Mailing Address - Country:US
Mailing Address - Phone:207-865-6131
Mailing Address - Fax:207-865-9399
Practice Address - Street 1:50 MARQUIS RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-6477
Practice Address - Country:US
Practice Address - Phone:207-865-6131
Practice Address - Fax:207-865-9399
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ2088207R00000X
390200000X
MEDO2838207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX345061102Medicaid
ME1356637805Medicaid
TX345061101Medicaid
TX379203YLP1OtherMEDICARE PTAN
TX379203YLP2OtherMEDICARE PTAN