Provider Demographics
NPI:1013911916
Name:WOODARD, WYATT D (MSN, FNP)
Entity Type:Individual
Prefix:
First Name:WYATT
Middle Name:D
Last Name:WOODARD
Suffix:
Gender:M
Credentials:MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 N LEROUX ST
Mailing Address - Street 2:STE B
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4535
Mailing Address - Country:US
Mailing Address - Phone:928-779-0361
Mailing Address - Fax:928-779-7143
Practice Address - Street 1:320 N LEROUX ST
Practice Address - Street 2:STE B
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4535
Practice Address - Country:US
Practice Address - Phone:928-779-0361
Practice Address - Fax:928-779-7143
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1235363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ83068Medicare PIN
AZ83066Medicare PIN
AZP38087Medicare UPIN