Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 5563 | OK |
N | 1223X0400X | Orthodontists | 151 | OK |
NPI | 1013021039 |
---|---|
Provider Name | Mr. Wayne Nolan Wyatt |
First Address | Tulsa, OK 74133-4583 |
Second Address | Tulsa, OK 74133-4583 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/08/2006 |
Last Update Date | 29/07/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200044110 | (05) | OK |