Provider Demographics
NPI:1568107134
Name:NELSON, WYATT ANDREW
Entity Type:Individual
Prefix:
First Name:WYATT
Middle Name:ANDREW
Last Name:NELSON
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 1:616 1/2 WASHBURN AVE
Mailing Address - Street 2:
Mailing Address - City:LYNDON
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4728
Mailing Address - Country:US
Mailing Address - Phone:618-384-8972
Mailing Address - Fax:
Practice Address - Street 1:500 S PRESTON ST RM 305
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1702
Practice Address - Country:US
Practice Address - Phone:502-852-5193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program