Provider Demographics
NPI:1588845762
Name:WYCHE, JAMES REGINALD (IDC)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:REGINALD
Last Name:WYCHE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 RADFORD BLVD
Mailing Address - Street 2:PSC 20012
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31704-1130
Mailing Address - Country:US
Mailing Address - Phone:229-369-7764
Mailing Address - Fax:
Practice Address - Street 1:814 RADFORD BLVD
Practice Address - Street 2:SUITE 20328
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31704-1130
Practice Address - Country:US
Practice Address - Phone:229-639-7764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman