Healthcare Provider Details

I. General information

NPI: 1699652545
Provider Name (Legal Business Name): GRANT WYSONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2025
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7250 CLEARVISTA DR STE 355
INDIANAPOLIS IN
46256-5609
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-6262
  • Fax:
Mailing address:
  • Phone: 317-621-1699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number28222590A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number71016996A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: