Provider Demographics
NPI:1740592617
Name:WYSOCKI, KATIE LYNN (PA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNN
Last Name:WYSOCKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-5009
Mailing Address - Country:US
Mailing Address - Phone:802-447-5519
Mailing Address - Fax:
Practice Address - Street 1:140 HOSPITAL DR STE 108
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-5010
Practice Address - Country:US
Practice Address - Phone:802-447-5519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA100218363AM0700X
VT0550031179363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03349671Medicaid
NYJ400048129Medicare PIN