MEDICARE: SCOTT R. WYSOWSKI PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA04750	TX

General Provider Information

NPI Number	:	1770693640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SCOTT R. WYSOWSKI PA-C

Provider Business Mailing Address
First Line	:	2535 IRA E WOODS AVE
Second Line	:
City	:	GRAPEVINE
State	:	TX
Zip	:	76051-3930
Country	:	US
Telephone Number	:	817-481-2121
Fax Number	:	817-488-4493

Provider Business Practice Location Address
First Line	:	4501 HERITAGE TRACE PKWY STE 101
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-8941
Country	:	US
Telephone Number	:	817-481-2121
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	01/04/2022

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