Provider Demographics
NPI:1427025642
Name:WYATT, THOMAS EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:EDWARD
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 1:5435 FELTL RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-7983
Mailing Address - Country:US
Mailing Address - Phone:952-835-9880
Mailing Address - Fax:952-857-1554
Practice Address - Street 1:4050 COON RAPIDS BLVD
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433
Practice Address - Country:US
Practice Address - Phone:763-236-7144
Practice Address - Fax:763-236-7733
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45311207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN313697300Medicaid
45311OtherMN MEDICAL LICENSE
45311OtherMN MEDICAL LICENSE
930001889Medicare ID - Type Unspecified