Provider Demographics
NPI:1598898371
Name:WYATT, GINA M (MD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:WYATT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 25TH AVE N STE 1204
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1620
Mailing Address - Country:US
Mailing Address - Phone:615-312-0600
Mailing Address - Fax:615-320-3259
Practice Address - Street 1:210 25TH AVE N STE 1204
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1620
Practice Address - Country:US
Practice Address - Phone:615-312-0600
Practice Address - Fax:615-320-3259
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD435702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1504830Medicaid
TN1505028Medicaid
KY7100061080Medicaid
P00640522OtherRAILROAD MEDICARE
TN4185805OtherBCBS
TNP00732359OtherRAILROAD MEDICARE (CIC)
TN4186061OtherBCBS
TN4186061OtherBCBS
TN1504830Medicaid