Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | MD19591 | ME |
Y | 2080P0214X | Pediatric Pulmonologist | MD19591 | ME |
NPI | 1073788956 |
---|---|
Provider Name | Dr. Colby A Wyatt |
First Address | Scarborough, ME 04074 |
Second Address | Portland, ME 04102 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/04/2008 |
Last Update Date | 05/09/2013 |