Provider Demographics
NPI:1679034698
Name:WYATT, RICHARD ALLEN JR (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLEN
Last Name:WYATT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 CASCADE LN
Mailing Address - Street 2:
Mailing Address - City:CAVE SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72718-9430
Mailing Address - Country:US
Mailing Address - Phone:501-658-0123
Mailing Address - Fax:
Practice Address - Street 1:378 S PINNACLE HILLS PKWY
Practice Address - Street 2:STE 100
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758
Practice Address - Country:US
Practice Address - Phone:479-757-4772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-31
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ARE-16452207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program