Provider Demographics
NPI:1982624169
Name:WAYT, WAYNE D (PAC)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:D
Last Name:WAYT
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 TELLURIDE DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76001-8518
Mailing Address - Country:US
Mailing Address - Phone:817-688-6152
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-606-4262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04132363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX290254618Medicaid
PA04132OtherPHYSICIAN ASSISTANTS
TX1J7443OtherMEDICARE
TXP02601593OtherMCRR
TX290254601Medicaid
TX1J7442OtherMEDICARE
TX290254603Medicaid
TX290254602Medicaid
TXQ00010982OtherMCRR