| Doctor Name: | CHANTEE I WYATT |
| NPI Number: | 1104135326 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | PA |
| License Number: | 7766525-1206 |
| Business Practice Address: | 47 N 1st E Preston, ID - 832631325 |
| Business Phone Number: | 2088522900 |
| Business Fax Number: | 2088523511 |
| Mailing Address: | 1593 E 400 N, PRESTON |
| State: | ID |
| Postal Code: | 832635395 |
| Phone Number: | 2088522900 |
| Fax Number: | 2088523511 |
| NPI Enumeration Date: | 10/05/2010 |
| NPI Last Update Date: | 11/06/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | 7766525-1206 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | UT |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |