Provider Demographics
NPI:1912948902
Name:WYATT, RICHARD A (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
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 1:9500 KANIS RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6324
Mailing Address - Country:US
Mailing Address - Phone:501-224-6699
Mailing Address - Fax:501-224-7752
Practice Address - Street 1:9500 KANIS RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6324
Practice Address - Country:US
Practice Address - Phone:501-224-6699
Practice Address - Fax:501-224-7752
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN-6335207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102659001Medicaid
AR160015704OtherRAILROAD MEDICARE
AR55878OtherBCBS
AR862499OtherUNITED HEALTHCARE
AR710619986OtherCIGNA
AR114860000-00OtherQUALCHOICE
AR4206569OtherAETNA
AR710619986OtherCIGNA
AR55878Medicare PIN