Provider Demographics
NPI:1043370547
Name:WYATT, LISA A (OD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:WYATT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4104 LA VISTA RD.
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084
Mailing Address - Country:US
Mailing Address - Phone:770-493-6490
Mailing Address - Fax:770-493-7909
Practice Address - Street 1:4104 LA VISTA RD.
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084
Practice Address - Country:US
Practice Address - Phone:770-493-6490
Practice Address - Fax:770-493-7909
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001526152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist