Provider Demographics
NPI:1558309013
Name:WYATT, HALSEY A (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:HALSEY
Middle Name:A
Last Name:WYATT
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5214 ANNUNCIATION ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-1816
Mailing Address - Country:US
Mailing Address - Phone:504-669-9084
Mailing Address - Fax:504-304-3231
Practice Address - Street 1:5214 ANNUNCIATION ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-1816
Practice Address - Country:US
Practice Address - Phone:504-669-9084
Practice Address - Fax:504-304-3231
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15828R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1076317Medicaid
LA4K055Medicare ID - Type Unspecified
LA1076317Medicaid