Provider Demographics
NPI:1831338391
Name:WYATT WEBB MD PA
Entity type:Organization
Organization Name:WYATT WEBB MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LENORA
Authorized Official - Middle Name:
Authorized Official - Last Name:FELAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-310-3734
Mailing Address - Street 1:1001 W SOUTHLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6010
Mailing Address - Country:US
Mailing Address - Phone:817-310-3734
Mailing Address - Fax:817-310-3767
Practice Address - Street 1:1001 W SOUTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6010
Practice Address - Country:US
Practice Address - Phone:817-310-3734
Practice Address - Fax:817-310-3767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-06
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2738261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5L710Medicare PIN