Provider Demographics
NPI:1649744822
Name:BARNES, WYLIE LEROY (ACNP)
Entity Type:Individual
Prefix:
First Name:WYLIE
Middle Name:LEROY
Last Name:BARNES
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 S PENN ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-7232
Mailing Address - Country:US
Mailing Address - Phone:605-290-7951
Mailing Address - Fax:
Practice Address - Street 1:1118 S PENN ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-7232
Practice Address - Country:US
Practice Address - Phone:605-290-7951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001509363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care