Provider Demographics
NPI:1205106523
Name:WYATT, JOHN ROBERT JR (CRNA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ROBERT
Last Name:WYATT
Suffix:JR
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 1:3 LUKAS CV
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-7567
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 W KINGSHIGHWAY
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450
Practice Address - Country:US
Practice Address - Phone:870-239-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-03
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR077091163W00000X
MO2024036785367500000X
MS810543367500000X
TN16514367500000X
ARC002963367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse