Healthcare Provider Details

I. General information

NPI: 1346200060
Provider Name (Legal Business Name): MARK A WYSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 03/29/2024
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 E SHEA BLVD STE 100
PHOENIX AZ
85028-6031
US

IV. Provider business mailing address

4600 E SHEA BLVD STE 100
PHOENIX AZ
85028-6031
US

V. Phone/Fax

Practice location:
  • Phone: 602-955-8700
  • Fax: 602-553-8142
Mailing address:
  • Phone: 602-955-8700
  • Fax: 602-553-8142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12165
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: