Provider Demographics
NPI:1811043862
Name:WYLIE, BRYCE DAVID (PA-C)
Entity type:Individual
Prefix:
First Name:BRYCE
Middle Name:DAVID
Last Name:WYLIE
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:PO BOX 18
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:ID
Mailing Address - Zip Code:83445-0018
Mailing Address - Country:US
Mailing Address - Phone:208-356-4900
Mailing Address - Fax:208-624-4112
Practice Address - Street 1:335 E MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:SAINT ANTHONY
Practice Address - State:ID
Practice Address - Zip Code:83445-1546
Practice Address - Country:US
Practice Address - Phone:208-356-4900
Practice Address - Fax:208-624-4116
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1013363A00000X, 363AM0700X
IDPA630363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805168100Medicaid
ID805168100Medicaid