Provider Demographics
NPI:1639989379
Name:GOTTSCHALK, WYATT JEFFRY
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:JEFFRY
Last Name:GOTTSCHALK
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 1:3304 SHOAFF PARK RIVER DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-2035
Mailing Address - Country:US
Mailing Address - Phone:260-804-4346
Mailing Address - Fax:
Practice Address - Street 1:608 UNION CHAPEL RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-9357
Practice Address - Country:US
Practice Address - Phone:260-248-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant