Provider Demographics
NPI:1992874622
Name:WYATT, DARCY POPE (DC)
Entity type:Individual
Prefix:MRS
First Name:DARCY
Middle Name:POPE
Last Name:WYATT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MS
Other - First Name:DARCY
Other - Middle Name:ALAINE
Other - Last Name:POPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1120 E MANANA
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101
Mailing Address - Country:US
Mailing Address - Phone:505-742-2117
Mailing Address - Fax:505-769-1010
Practice Address - Street 1:1120 E MANANA
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:505-742-2117
Practice Address - Fax:505-769-1010
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1531111N00000X
TX9124111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMDC5428OtherMEDICARE-RAILROAD
NMDC5428OtherMEDICARE-RAILROAD
V0042935Medicare UPIN