Provider Demographics
NPI:1457344541
Name:WYSHAM, CAROL H (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:H
Last Name:WYSHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:D
Other - Last Name:HATCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3649
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220-3649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1334
Practice Address - Country:US
Practice Address - Phone:509-838-2531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029515207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8136434Medicaid
WA8136434Medicaid
D81641Medicare UPIN