Provider Demographics
NPI:1538490297
Name:WYATT, KIMBERLY ANNE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:ANNE
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 1:709 HOLLYBROOK DR STE 4500
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-2412
Mailing Address - Country:US
Mailing Address - Phone:903-291-6287
Mailing Address - Fax:903-291-6286
Practice Address - Street 1:709 HOLLYBROOK DR STE 4500
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2412
Practice Address - Country:US
Practice Address - Phone:903-291-6287
Practice Address - Fax:903-291-6286
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1091066363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1091066OtherNCCPA CERTIFICATION
TX210972002Medicaid
TX348877YKS4Medicare PIN