Provider Demographics
NPI:1497740989
Name:WYANT, FRANK WILLIS JR (DO)
Entity Type:Individual
Prefix:
First Name:FRANK
Middle Name:WILLIS
Last Name:WYANT
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8801 HORIZON BLVD NE
Mailing Address - Street 2:SUITE 360
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1533
Mailing Address - Country:US
Mailing Address - Phone:505-828-4923
Mailing Address - Fax:505-213-0103
Practice Address - Street 1:806 DR. MLK JR. AVE., NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102
Practice Address - Country:US
Practice Address - Phone:505-842-6575
Practice Address - Fax:505-764-8796
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-864-87207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM40394Medicaid
NM180014481OtherRRB MEDICARE RAILROAD
NMNM004657OtherBC BS OF NM
AZ279712Medicaid
NM40394Medicaid
NM180014481OtherRRB MEDICARE RAILROAD