Provider Demographics
NPI:1821139510
Name:WYANT, GLEN R (MD)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:R
Last Name:WYANT
Suffix:
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 1:7000 W PLANO PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-8465
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 STANTON L YOUNG BLVD STE 1140
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5036
Practice Address - Country:US
Practice Address - Phone:405-271-4351
Practice Address - Fax:405-271-8695
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8898207L00000X, 207LP3000X
OK27000207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138661714Medicaid
TXB90069Medicare UPIN
TX138661714Medicaid