Provider Demographics
NPI:1184728537
Name:WYATT, WILLIAM JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JOSEPH
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 1:505 S BURG ST
Mailing Address - Street 2:
Mailing Address - City:KIMBALL
Mailing Address - State:NE
Mailing Address - Zip Code:69145-1313
Mailing Address - Country:US
Mailing Address - Phone:308-235-1951
Mailing Address - Fax:308-235-1954
Practice Address - Street 1:505 S BURG ST
Practice Address - Street 2:
Practice Address - City:KIMBALL
Practice Address - State:NE
Practice Address - Zip Code:69145-1313
Practice Address - Country:US
Practice Address - Phone:308-235-1951
Practice Address - Fax:308-235-1954
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE20963208200000X, 2082S0105X, 2086S0122X
WY6212A208200000X, 2082S0105X, 208600000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY113999100Medicaid
WY102753300OtherWORKERS COMP
WY113999100Medicare ID - Type Unspecified
WY102753300OtherWORKERS COMP
E48364Medicare UPIN