Provider Demographics
NPI:1700082104
Name:WYATT, P WADE (MD)
Entity type:Individual
Prefix:
First Name:P
Middle Name:WADE
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 1:1901 W PARKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119
Mailing Address - Country:US
Mailing Address - Phone:801-886-2020
Mailing Address - Fax:801-954-0054
Practice Address - Street 1:4878 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-6007
Practice Address - Country:US
Practice Address - Phone:801-272-8861
Practice Address - Fax:801-272-8867
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT64451081205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1700082104Medicaid
UT0618950016Medicare NSC
UT000062823Medicare PIN
UT1700082104Medicaid
UT0618950014Medicare NSC
UT000062811Medicare PIN
UT000062819Medicare PIN
UT0618950019Medicare NSC
UT000062824Medicare PIN
UT000062820Medicare PIN
UT0618950018Medicare NSC
UT0618950012Medicare NSC
UT0618950009Medicare NSC
UT000062822Medicare PIN
UT0618950017Medicare NSC
UTP00473212Medicare PIN
UT000062825Medicare PIN
UT000062818Medicare PIN
UT000062816Medicare PIN
UT0618950010Medicare NSC
UT0618950002Medicare NSC
UT000062815Medicare PIN
UT0618950007Medicare NSC
UT0618950005Medicare NSC
UT000062826Medicare PIN