Provider Demographics
NPI:1467041400
Name:WYATT, JAEL CHARLENE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JAEL
Middle Name:CHARLENE
Last Name:WYATT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 FRANCISCAN DR
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2544
Mailing Address - Country:US
Mailing Address - Phone:979-776-2568
Mailing Address - Fax:
Practice Address - Street 1:3804 HIGHWAY 377 S
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801-5120
Practice Address - Country:US
Practice Address - Phone:325-643-5167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant