Doctor Name: | MR. CHARLES MANSON WYATT |
NPI Number: | 1063481018 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | PA-C |
License Number: | 100493 |
Business Practice Address: | M-48611 Logistics Ave Joel Health Clinic Fort Bragg, NC - 283100001 |
Business Phone Number: | 9109079166 |
Business Fax Number: | |
Mailing Address: | 2539 Cameron Woods Ln, FAYETTEVILLE |
State: | NC |
Postal Code: | 283067782 |
Phone Number: | 9109079116 |
Fax Number: | 9109079828 |
NPI Enumeration Date: | 03/14/2006 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363AM0700X |
License Number: | 100493 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | NC |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Physician Assistant |
Taxonomy Specialization: | Medical |
Taxonomy Definition: |