Provider Demographics
NPI:1639162787
Name:WYSOSKI, PAUL W (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:W
Last Name:WYSOSKI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 HIGHWAY 29 S
Mailing Address - Street 2:STE 4155
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-3486
Mailing Address - Country:US
Mailing Address - Phone:320-759-1130
Mailing Address - Fax:320-759-1129
Practice Address - Street 1:3015 HIGHWAY 29 S
Practice Address - Street 2:STE 4155
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3486
Practice Address - Country:US
Practice Address - Phone:320-759-1130
Practice Address - Fax:320-759-1129
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2383152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
66Q26RUOtherBCBS
30701135OtherPW
66Q23RUOtherBCBS
66Q23RUOtherBCBS