Provider Demographics
NPI:1346200060
Name:WYSE, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:WYSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4600 E SHEA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-6031
Mailing Address - Country:US
Mailing Address - Phone:602-955-8700
Mailing Address - Fax:602-553-8142
Practice Address - Street 1:4600 E SHEA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-6031
Practice Address - Country:US
Practice Address - Phone:602-955-8700
Practice Address - Fax:602-553-8142
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ12165207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ12165OtherLICENSE
AZ12165OtherLICENSE
AZ12165OtherLICENSE