Provider Demographics
NPI:1578550257
Name:WYATT, JIMMY ALLEN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:ALLEN
Last Name:WYATT
Suffix:
Gender:M
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 1:1808 NEEDLE PALM DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32132-3322
Mailing Address - Country:US
Mailing Address - Phone:386-424-0158
Mailing Address - Fax:
Practice Address - Street 1:350 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2733
Practice Address - Country:US
Practice Address - Phone:386-238-3289
Practice Address - Fax:386-238-3296
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103344363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical