Provider Demographics
NPI:1437359544
Name:WYSOR, MICHAEL SANDERS (MD,PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SANDERS
Last Name:WYSOR
Suffix:
Gender:M
Credentials:MD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 FORT HENRY DR
Mailing Address - Street 2:SUITE10
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-5305
Mailing Address - Country:US
Mailing Address - Phone:423-239-6791
Mailing Address - Fax:
Practice Address - Street 1:5400 FORT HENRY DR
Practice Address - Street 2:SUITE10
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-5305
Practice Address - Country:US
Practice Address - Phone:423-239-6791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000025940208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
F99482Medicare UPIN
3897759Medicare PIN