Provider Demographics
NPI:1699713412
Name:WYATT, MICHELLE T (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:T
Last Name:WYATT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1056 GREEN ACRES RD # 102-385
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97408-1505
Mailing Address - Country:US
Mailing Address - Phone:541-515-6593
Mailing Address - Fax:351-207-3929
Practice Address - Street 1:1056 GREEN ACRES RD # 102-385
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97408-1505
Practice Address - Country:US
Practice Address - Phone:541-515-6593
Practice Address - Fax:351-207-3929
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18696207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORF88880Medicare UPIN