Provider Demographics
NPI:1982819199
Name:WYATT, PHILIP RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:RICHARD
Last Name:WYATT
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 1:3101 OLD PECOS TRL
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-9025
Mailing Address - Country:US
Mailing Address - Phone:505-438-2211
Mailing Address - Fax:505-438-2220
Practice Address - Street 1:3101 OLD PECOS TRL
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-9025
Practice Address - Country:US
Practice Address - Phone:505-438-2211
Practice Address - Fax:505-438-2220
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21374170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical Genetics