Provider Demographics
NPI:1104135326
Name:WYATT, CHANTEE I (PA-C)
Entity type:Individual
Prefix:
First Name:CHANTEE
Middle Name:I
Last Name:WYATT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 N 200 E
Mailing Address - Street 2:SUITE #250
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341
Mailing Address - Country:US
Mailing Address - Phone:435-363-7853
Mailing Address - Fax:435-799-3598
Practice Address - Street 1:1451 N 200 E SUITE #250
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341
Practice Address - Country:US
Practice Address - Phone:435-363-7853
Practice Address - Fax:435-799-3598
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1182363A00000X
UT7766525-1206207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1104135326Medicaid
IDPA-1182OtherPHYSICIAN ASSISTANT LICENSE