Individual
CHANTEE I WYATT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
1451 N 200 E SUITE #250, LOGAN, UT 84341
(435) 363-7853
(435) 799-3598
Mailing address
1451 N 200 E, SUITE #250, LOGAN, UT 84341
(435) 363-7853
(435) 799-3598
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
7766525-1206
UT
363A00000X
Physician Assistant
PA-1182
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1104135326
—
ID
01
—
PA-1182
PHYSICIAN ASSISTANT LICENSE
ID
Enumeration date
10/05/2010
Last updated
10/21/2024
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