Provider Demographics
NPI:1326617937
Name:WYATT, RANDALL DELBERT (RN, CRNA)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:DELBERT
Last Name:WYATT
Suffix:
Gender:M
Credentials:RN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 843603
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-3603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10315 DAWSONS CREEK BLVD STE AB
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1912
Practice Address - Country:US
Practice Address - Phone:260-436-7875
Practice Address - Fax:260-432-9812
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28246441A367500000X, 163WC0200X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1326617937Medicaid
IN1326617937Medicaid