Provider Demographics
NPI:1295774115
Name:WYANT, JESSICA EVANGELINE (MD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:EVANGELINE
Last Name:WYANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:700 2ND ST NE
Practice Address - Street 2:KAISER PERMANENTE CAPITOL HILL MEDICAL CENTER
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-8100
Practice Address - Country:US
Practice Address - Phone:202-346-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD53727207P00000X
DCMD035355207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD552301000Medicaid
H02264Medicare UPIN
MD688FMedicare ID - Type Unspecified