Provider Demographics
NPI:1578797122
Name:WYATT WOODARD MSN FNP PLLC
Entity Type:Organization
Organization Name:WYATT WOODARD MSN FNP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WYATT
Authorized Official - Middle Name:D
Authorized Official - Last Name:WOODARD
Authorized Official - Suffix:
Authorized Official - Credentials:MSN FNP
Authorized Official - Phone:928-779-0361
Mailing Address - Street 1:320 N LEROUX ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4535
Mailing Address - Country:US
Mailing Address - Phone:928-779-0361
Mailing Address - Fax:928-779-7143
Practice Address - Street 1:320 N. LEROUX
Practice Address - Street 2:SUITE B
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4535
Practice Address - Country:US
Practice Address - Phone:928-779-0361
Practice Address - Fax:928-779-7143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-12
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1235363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ83066Medicare PIN