Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 26NJ00996800 | NJ |
Y | 111NI0900X | Internist | 26NJ00996800 | NJ |
N | 207RP1001X | Pulmonary Disease | 26NJ00996800 | NJ |
NPI | 1033756044 |
---|---|
Provider Name | Kelly Wyatt |
First Address | Aston, PA 19014-1100 |
Second Address | Salem, NJ 08079-2053 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/12/2019 |
Last Update Date | 07/09/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1033756044 | (05) | NJ |