Healthcare Provider Details

I. General information

NPI: 1194373043
Provider Name (Legal Business Name): MICHAEL MARLIN WYSINGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 N MONROE ST STE 2
MARKSVILLE LA
71351-2311
US

IV. Provider business mailing address

1000 CHINABERRY DR
BOSSIER CITY LA
71111-2442
US

V. Phone/Fax

Practice location:
  • Phone: 318-240-7278
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: