Provider Demographics
NPI:1962606558
Name:WYATT, DONNA LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:DONNA
Middle Name:LYNN
Last Name:WYATT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-2609
Practice Address - Street 1:1701 JIMMIE DAVIS HWY
Practice Address - Street 2:STE 200
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-4515
Practice Address - Country:US
Practice Address - Phone:318-681-1660
Practice Address - Fax:318-681-1661
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3885207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
3853003324OtherMYUTMB 3853003324-COMMERCIAL NUMBER
LA2350471Medicaid
3853003324OtherMYUTMB 3853003324-COMMERCIAL NUMBER
TXTXB105393Medicare PIN