Provider Demographics
NPI:1104824648
Name:WYMAN, MICHAEL BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRUCE
Last Name:WYMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 NE HOYT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2991
Mailing Address - Country:US
Mailing Address - Phone:503-234-9861
Mailing Address - Fax:503-238-0873
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:SUITE 340
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2991
Practice Address - Country:US
Practice Address - Phone:503-234-9861
Practice Address - Fax:503-238-0873
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13922174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR202739Medicaid
ORC91472Medicare UPIN
OR202739Medicaid