Healthcare Provider Details

I. General information

NPI: 1760742738
Provider Name (Legal Business Name): MICHAEL EUGENE WYLIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HEADQUARTERS, US ARMY MEDICAL DEPARTMENT ACTIVITY-JAPAN BG CRAWFORD F. SAMS, US ARMY HEALTH CLINIC, UNIT 45011
APO AP
96343-5011
US

IV. Provider business mailing address

UNIT 45013 BOX 2803
APO AP
96338-5013
US

V. Phone/Fax

Practice location:
  • Phone: 315-263-2807
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberE1560296
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: