Provider Demographics
NPI:1245549336
Name:WYSE, NICOLE MICHELLE (PA-C)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:MICHELLE
Last Name:WYSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2599 WEXFORD BAYNE RD
Mailing Address - Street 2:
Mailing Address - City:SEWICKLEY
Mailing Address - State:PA
Mailing Address - Zip Code:15143-8769
Mailing Address - Country:US
Mailing Address - Phone:724-933-3644
Mailing Address - Fax:
Practice Address - Street 1:2599 WEXFORD BAYNE RD
Practice Address - Street 2:
Practice Address - City:SEWICKLEY
Practice Address - State:PA
Practice Address - Zip Code:15143-8769
Practice Address - Country:US
Practice Address - Phone:724-933-3644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-06
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054586363AS0400X
MA054586363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical