Provider Demographics
NPI:1427576388
Name:WYATT, BRANTLEY AARON (CAA)
Entity Type:Individual
Prefix:
First Name:BRANTLEY
Middle Name:AARON
Last Name:WYATT
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3209
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3209
Mailing Address - Country:US
Mailing Address - Phone:317-614-9874
Mailing Address - Fax:317-428-1055
Practice Address - Street 1:1199 PRINCE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2797
Practice Address - Country:US
Practice Address - Phone:706-475-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant