Individual
JEFFREY BROCK WYATT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
415 S 28TH AVE, HATTIESBURG, MS 39401-7246
(601) 261-3606
(601) 579-5383
Mailing address
415 S 28TH AVE, HATTIESBURG, MS 39401-7246
(601) 261-3606
(601) 579-5240
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
R864932
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01656892
—
MS
Enumeration date
10/17/2011
Last updated
08/10/2020
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