Healthcare Provider Details

I. General information

NPI: 1780853085
Provider Name (Legal Business Name): RACHAEL K WYMER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2008
Last Update Date: 11/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 E VALLEY RD SUITE 201
BASALT CO
81621-8304
US

IV. Provider business mailing address

100 E MAIN ST SUITE 101
ASPEN CO
81611-1780
US

V. Phone/Fax

Practice location:
  • Phone: 970-927-8611
  • Fax:
Mailing address:
  • Phone: 970-925-4141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-003184
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2922
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: