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 92
Mailing Address - Street 2:
Mailing Address - City:DRAYTON
Mailing Address - State:SC
Mailing Address - Zip Code:29333-0092
Mailing Address - Country:US
Mailing Address - Phone:828-226-3784
Mailing Address - Fax:
Practice Address - Street 1:3660 VISTA AVE STE 312
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2540
Practice Address - Country:US
Practice Address - Phone:314-577-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-14
Last Update Date:2023-08-03
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