Provider Demographics
NPI:1639280431
Name:WYATT CLINIC, P.A.
Entity Type:Organization
Organization Name:WYATT CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPMSM, CPCS
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:HURT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-355-8900
Mailing Address - Street 1:1411 E. AMARILLO BLVD.
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79107-5555
Mailing Address - Country:US
Mailing Address - Phone:806-354-1015
Mailing Address - Fax:806-351-7274
Practice Address - Street 1:1411 E AMARILLO BLVD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79107-5555
Practice Address - Country:US
Practice Address - Phone:806-351-7200
Practice Address - Fax:806-351-7274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168039901Medicaid
TX168039901Medicaid