Provider Demographics
NPI:1720030901
Name:WYATT, SUSAN G (CRNA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:G
Last Name:WYATT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:DIANE
Other - Last Name:GAUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 235022
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36123-5022
Mailing Address - Country:US
Mailing Address - Phone:334-386-2051
Mailing Address - Fax:334-396-6929
Practice Address - Street 1:2105 EAST SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116
Practice Address - Country:US
Practice Address - Phone:334-288-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1035451367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051552510Medicaid
AL051513181OtherBLUE CROSS
AL051513181OtherBLUE CROSS
AL051552510Medicare ID - Type Unspecified