Provider Demographics
NPI:1134271125
Name:WYATT, JEFFERY DALE (CRNA)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:DALE
Last Name:WYATT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 A J WYATT LOOP RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71251-7503
Mailing Address - Country:US
Mailing Address - Phone:318-259-1242
Mailing Address - Fax:
Practice Address - Street 1:301 W BOUNDARY AVE
Practice Address - Street 2:
Practice Address - City:WINNFIELD
Practice Address - State:LA
Practice Address - Zip Code:71483-3427
Practice Address - Country:US
Practice Address - Phone:318-648-3072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN075781 APO4189367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered