Provider Demographics
NPI:1720337462
Name:WYATT, SCOTT B (IDMT)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:B
Last Name:WYATT
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 MEADOWLARK ST
Mailing Address - Street 2:
Mailing Address - City:SHAW AFB
Mailing Address - State:SC
Mailing Address - Zip Code:29152-5019
Mailing Address - Country:US
Mailing Address - Phone:321-961-1447
Mailing Address - Fax:
Practice Address - Street 1:431 MEADOWLARK ST
Practice Address - Street 2:
Practice Address - City:SHAW AFB
Practice Address - State:SC
Practice Address - Zip Code:29152-5019
Practice Address - Country:US
Practice Address - Phone:321-961-1447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians