Provider Demographics
NPI:1780853085
Name:WYMER, RACHAEL K (PA)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:K
Last Name:WYMER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 E MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81611-1780
Mailing Address - Country:US
Mailing Address - Phone:970-925-4141
Mailing Address - Fax:
Practice Address - Street 1:1450 E VALLEY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621-8304
Practice Address - Country:US
Practice Address - Phone:970-927-8611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-21
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085-003184363A00000X
CO2922363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant