Individual
MR. WYATT RANDOLPH EDDY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MS, MMS, PA-C
Contact information
Practice address
3269 STOCKTON HILL RD, KINGMAN, AZ 86409-3619
(928) 757-2101
Mailing address
3269 N STOCKTON HILL RD, KINGMAN, AZ 86409-3619
(928) 757-2101
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
6055
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
033429
—
AZ
Enumeration date
06/25/2015
Last updated
12/23/2020
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