Healthcare Provider Details

I. General information

NPI: 1639162787
Provider Name (Legal Business Name): PAUL W WYSOSKI OD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 HIGHWAY 29 S STE 4155
ALEXANDRIA MN
56308-3486
US

IV. Provider business mailing address

3015 HIGHWAY 29 S STE 4155
ALEXANDRIA MN
56308-3486
US

V. Phone/Fax

Practice location:
  • Phone: 320-759-1130
  • Fax: 320-759-1129
Mailing address:
  • Phone: 320-759-1130
  • Fax: 320-759-1129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2383
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: