Provider Demographics
NPI:1154399095
Name:WYATT, RONNIE (PA)
Entity type:Individual
Prefix:MR
First Name:RONNIE
Middle Name:
Last Name:WYATT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 STRATFORD DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-4702
Mailing Address - Country:US
Mailing Address - Phone:863-644-1255
Mailing Address - Fax:
Practice Address - Street 1:1417 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3200
Practice Address - Country:US
Practice Address - Phone:863-682-8401
Practice Address - Fax:863-802-9611
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1709363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE1779BMedicare ID - Type Unspecified
S69022Medicare UPIN