Provider Demographics
NPI:1114185907
Name:WYSE, SHELLEY LYNN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:LYNN
Last Name:WYSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:LYNN
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 BRADENTON AVE
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-7515
Mailing Address - Country:US
Mailing Address - Phone:937-578-4040
Mailing Address - Fax:
Practice Address - Street 1:388 DAMASCUS RD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-5535
Practice Address - Country:US
Practice Address - Phone:937-578-4040
Practice Address - Fax:937-578-2591
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-1164363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical