Provider Demographics
NPI:1023094760
Name:HALL, WYATT JASON
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:JASON
Last Name:HALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:WYATT
Other - Middle Name:J
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1175
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80150-1175
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1950 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3129
Practice Address - Country:US
Practice Address - Phone:303-306-7783
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35957207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01359579Medicaid
CO930081384OtherRAILROAD MEDICARE PIN
CO01359579Medicaid
CO930081384OtherRAILROAD MEDICARE PIN