Provider Demographics
NPI:1538384490
Name:LYNN J WYATT
Entity type:Organization
Organization Name:LYNN J WYATT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:724-438-5120
Mailing Address - Street 1:18 NICKMAN PLAZA
Mailing Address - Street 2:
Mailing Address - City:LEMONT FURNACE
Mailing Address - State:PA
Mailing Address - Zip Code:15456
Mailing Address - Country:US
Mailing Address - Phone:724-438-5120
Mailing Address - Fax:724-438-5142
Practice Address - Street 1:18 NICKMAN PLAZA
Practice Address - Street 2:
Practice Address - City:LEMONT FURNACE
Practice Address - State:PA
Practice Address - Zip Code:15456
Practice Address - Country:US
Practice Address - Phone:724-438-5120
Practice Address - Fax:724-438-5142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAWY235185OtherBS
PAMA01532552Medicaid
PAMC235185Medicare ID - Type Unspecified
PA4288960001Medicare NSC