Provider Demographics
NPI:1245263086
Name:WYATT, JOAN M (MD)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:WYATT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:M
Other - Last Name:BARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3740 INTERNATIONAL GOLF PKWY
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-0665
Mailing Address - Country:US
Mailing Address - Phone:904-671-8333
Mailing Address - Fax:
Practice Address - Street 1:3740 INTERNATIONAL GOLF PKWY
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-0665
Practice Address - Country:US
Practice Address - Phone:904-671-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA052615207Q00000X
NY235566-1207Q00000X
CO44702207Q00000X
SD9268207Q00000X
FL132924207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO44071876Medicaid
G02701Medicare UPIN
G02701Medicare UPIN