Provider Demographics
NPI:1821773722
Name:WYATT, BRANDYN (OD)
Entity Type:Individual
Prefix:
First Name:BRANDYN
Middle Name:
Last Name:WYATT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 MARKET ST STE 20
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-2396
Mailing Address - Country:US
Mailing Address - Phone:541-451-2020
Mailing Address - Fax:541-451-1785
Practice Address - Street 1:90 MARKET ST STE 20
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-2396
Practice Address - Country:US
Practice Address - Phone:541-451-2020
Practice Address - Fax:541-451-1785
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4683ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist