Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | 226600 | NY |
Y | 207N00000X | Dermatologist | 42581 | AZ |
N | 207N00000X | Dermatologist | M4667 | TX |
N | 207ND0900X | Dermatopathologist | 226600 | NY |
N | 207ND0900X | Dermatopathologist | 42581 | AZ |
N | 207ND0900X | Dermatopathologist | M4667 | TX |
N | 207NP0225X | Pediatric Dermatologist | 226600 | NY |
N | 207NP0225X | Pediatric Dermatologist | 42581 | AZ |
N | 207NP0225X | Pediatric Dermatologist | M4667 | TX |
N | 207NS0135X | Procedural Dermatology | 226600 | NY |
N | 207NS0135X | Procedural Dermatology | 42581 | AZ |
N | 207NS0135X | Procedural Dermatology | M4667 | TX |
NPI | 1528011368 |
---|---|
Provider Name | Angela J Wyatt |
First Address | Flagstaff, AZ 86001-7304 |
Second Address | Flagstaff, AZ 86001-5257 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/05/2006 |
Last Update Date | 15/01/2019 |