Provider Demographics
NPI:1679319107
Name:TARLTON, WYATT WADE
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:WADE
Last Name:TARLTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10163 HIGHWAY 21 N
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:MS
Mailing Address - Zip Code:39354-8622
Mailing Address - Country:US
Mailing Address - Phone:601-504-5648
Mailing Address - Fax:
Practice Address - Street 1:10163 HIGHWAY 21 N
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:MS
Practice Address - Zip Code:39354-8622
Practice Address - Country:US
Practice Address - Phone:601-504-5648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program