Provider Demographics
NPI:1407542293
Name:WYATT, WILLIAM KING (APRN)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:KING
Last Name:WYATT
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14311 E 126TH ST N
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-4130
Mailing Address - Country:US
Mailing Address - Phone:918-640-4803
Mailing Address - Fax:
Practice Address - Street 1:14311 E 126TH ST N
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:OK
Practice Address - Zip Code:74021-4130
Practice Address - Country:US
Practice Address - Phone:918-640-4803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK78990363LF0000X
OK212533363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily