Provider Demographics
NPI:1508499856
Name:WYRICK, DALTON JACOB
Entity Type:Individual
Prefix:
First Name:DALTON
Middle Name:JACOB
Last Name:WYRICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5404 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74112-6304
Mailing Address - Country:US
Mailing Address - Phone:918-852-9840
Mailing Address - Fax:
Practice Address - Street 1:5404 E 14TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74112-6304
Practice Address - Country:US
Practice Address - Phone:918-852-9840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program