Provider Demographics
NPI:1457987166
Name:DANNER, WYATT HAYDEN
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:HAYDEN
Last Name:DANNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 797052
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63179-7000
Mailing Address - Country:US
Mailing Address - Phone:636-461-1414
Mailing Address - Fax:
Practice Address - Street 1:3619 RICHARDSON SQUARE DR STE 150
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-6021
Practice Address - Country:US
Practice Address - Phone:636-461-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-14
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2022046396207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program