Provider Demographics
NPI:1619597952
Name:WYATT, NATHAN ALAN
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:ALAN
Last Name:WYATT
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 1:2480 ARTZ RD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28146-1164
Mailing Address - Country:US
Mailing Address - Phone:704-213-9835
Mailing Address - Fax:
Practice Address - Street 1:900 BRANCHVIEW DR NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2213
Practice Address - Country:US
Practice Address - Phone:704-780-4271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-16
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst