Provider Demographics
NPI:1457348567
Name:WYSE, KATRINA ANITA (MD)
Entity Type:Individual
Prefix:DR
First Name:KATRINA
Middle Name:ANITA
Last Name:WYSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11123 PARKVIEW PLAZA DR STE 101
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1707
Practice Address - Country:US
Practice Address - Phone:260-425-6650
Practice Address - Fax:260-425-6649
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD423483207V00000X
IN10003376A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA096409E5FMedicare PIN
PAI-46453Medicare UPIN