Provider Demographics
NPI:1497731848
Name:WYATT, RONALD EVERETT (CRNA)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:EVERETT
Last Name:WYATT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 JAN LEE DR
Mailing Address - Street 2:
Mailing Address - City:BURKBURNETT
Mailing Address - State:TX
Mailing Address - Zip Code:76354-2916
Mailing Address - Country:US
Mailing Address - Phone:940-704-0456
Mailing Address - Fax:
Practice Address - Street 1:2200 BERQUIST DR
Practice Address - Street 2:59 MEDICAL WING/CREDENTIALS
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:76236-5300
Practice Address - Country:US
Practice Address - Phone:940-676-0868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX715033367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered