Provider Demographics
NPI:1649487430
Name:WYATT, CHRISTOPHER C (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:C
Last Name:WYATT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-0800
Mailing Address - Fax:208-302-0855
Practice Address - Street 1:1055 N CURTIS ROAD
Practice Address - Street 2:S6
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-302-0800
Practice Address - Fax:208-302-0855
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-10687207P00000X, 207PE0005X
IAR-7842207P00000X
ORMD183860207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI14628007Medicare PIN