Provider Demographics
NPI:1770693640
Name:WYSOWSKI, SCOTT R (PA-C)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:R
Last Name:WYSOWSKI
Suffix:
Gender:M
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 1:2535 IRA E WOODS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3930
Mailing Address - Country:US
Mailing Address - Phone:817-481-2121
Mailing Address - Fax:817-488-4493
Practice Address - Street 1:4501 HERITAGE TRACE PKWY STE 101
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-8941
Practice Address - Country:US
Practice Address - Phone:817-481-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04750363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G5299Medicare PIN