Provider Demographics
NPI:1659309136
Name:WYMAN, PETER A (PHD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:WYMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 CRITTENDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-6733
Mailing Address - Fax:
Practice Address - Street 1:300 CRITTENDEN BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-275-6733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9471103T00000X
NY009471103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02130569Medicaid
NY02130569Medicaid
NYJ400035603Medicare PIN