Basic Information
| Provider Information | |||||||||
| NPI: | 1164483210 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYANT | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80217 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850600217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023852115 | ||||||||
| FaxNumber: | 4804183323 | ||||||||
| Practice Location | |||||||||
| Address1: | 6116 E. ARBOR AVE | ||||||||
| Address2: | SUITE 118 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852065235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809241552 | ||||||||
| FaxNumber: | 4808308417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 0427 | AZ | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | AZ0194310 | 01 | AZ | BCBS | OTHER | 310160 | 05 | AZ | MEDICAID | P00275401 | 01 | AZ | MEDICARE RAILROAD | OTHER |