Healthcare Provider Details

I. General information

NPI: 1891807178
Provider Name (Legal Business Name): JEAN MARIE WYLES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 SE SUNNYSIDE RD SUNNYBROOK MEDICAL OFFICE
CLACKAMAS OR
97015
US

IV. Provider business mailing address

9900 SE SUNNYSIDE RD SUNNYBROOK MEDICAL OFFICE
CLACKAMAS OR
97015
US

V. Phone/Fax

Practice location:
  • Phone: 503-571-5887
  • Fax:
Mailing address:
  • Phone: 503-571-5887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberOR MD17834
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: