Provider Demographics
NPI:1134967888
Name:WYATT, ANDREW C (SOIDC)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:C
Last Name:WYATT
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 WHISTLER WOODS WAY
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-6681
Mailing Address - Country:US
Mailing Address - Phone:865-621-9183
Mailing Address - Fax:
Practice Address - Street 1:3D RECON BN
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96602-6180
Practice Address - Country:US
Practice Address - Phone:865-621-9183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman