Healthcare Provider Details

I. General information

NPI: 1699229054
Provider Name (Legal Business Name): KARLA MARIE WYTAS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KARLA MARIE DOS SANTOS

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 MAIN ST STE 5
SPRINGFIELD MA
01107-1147
US

IV. Provider business mailing address

3455 MAIN ST STE 5
SPRINGFIELD MA
01107-1147
US

V. Phone/Fax

Practice location:
  • Phone: 413-733-9600
  • Fax: 413-732-6534
Mailing address:
  • Phone: 413-733-9600
  • Fax: 413-732-6534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA5827
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: