Provider Demographics
NPI:1417382649
Name:WYATT, ALICIA R
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:R
Last Name:WYATT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SAINT FRANCIS
Mailing Address - State:KS
Mailing Address - Zip Code:67756-3540
Mailing Address - Country:US
Mailing Address - Phone:785-332-2104
Mailing Address - Fax:785-332-3255
Practice Address - Street 1:210 W 1ST ST
Practice Address - Street 2:
Practice Address - City:SAINT FRANCIS
Practice Address - State:KS
Practice Address - Zip Code:67756-3540
Practice Address - Country:US
Practice Address - Phone:785-332-2104
Practice Address - Fax:785-332-3255
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS43-557204367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30004530900001Medicaid