Provider Demographics
NPI:1952396434
Name:WYSOSKE, REBECCA L (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:WYSOSKE
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 1:985578 NEBRASKA MEDICAL CENTER
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-5578
Mailing Address - Country:US
Mailing Address - Phone:402-552-6007
Mailing Address - Fax:402-552-6225
Practice Address - Street 1:985578 NEBRASKA MEDICAL CENTER
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-5578
Practice Address - Country:US
Practice Address - Phone:402-552-6007
Practice Address - Fax:402-552-6225
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI465172084P0800X
NE219512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
E54295Medicare UPIN