Provider Demographics
NPI:1275219818
Name:WYLAM, ALEXIS R (OD)
Entity Type:Individual
Prefix:DR
First Name:ALEXIS
Middle Name:R
Last Name:WYLAM
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 1:312 COUNTRYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HANOVER TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18706-5311
Mailing Address - Country:US
Mailing Address - Phone:570-606-9234
Mailing Address - Fax:
Practice Address - Street 1:281 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:HAZLE TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18202-3320
Practice Address - Country:US
Practice Address - Phone:570-453-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG004023152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management