Provider Demographics
NPI:1588031314
Name:WYETH, JOSHUA
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:WYETH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:HILLMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49746-0427
Mailing Address - Country:US
Mailing Address - Phone:989-354-2197
Mailing Address - Fax:989-356-6524
Practice Address - Street 1:21258 M 68 HWY
Practice Address - Street 2:
Practice Address - City:ONAWAY
Practice Address - State:MI
Practice Address - Zip Code:49765-9692
Practice Address - Country:US
Practice Address - Phone:989-733-2082
Practice Address - Fax:989-733-8487
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007516363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPENDINGMedicare PIN