Provider Demographics
NPI:1013074368
Name:WYANT, LINDSAY EVELYN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:LINDSAY
Middle Name:EVELYN
Last Name:WYANT
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:LINDSAY
Other - Middle Name:EVELYN
Other - Last Name:DREW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:3303 S BOND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4501
Mailing Address - Country:US
Mailing Address - Phone:503-494-8510
Mailing Address - Fax:503-494-4631
Practice Address - Street 1:3303 S BOND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-494-8510
Practice Address - Fax:503-494-4631
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA00992363A00000X
ORPA00992363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q32677Medicare UPIN
103285Medicare ID - Type Unspecified