Healthcare Provider Details

I. General information

NPI: 1275219818
Provider Name (Legal Business Name): ALEXIS R WYLAM OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 AIRPORT RD
HAZLE TOWNSHIP PA
18202-3320
US

IV. Provider business mailing address

312 COUNTRYWOOD DR
HANOVER TOWNSHIP PA
18706-5311
US

V. Phone/Fax

Practice location:
  • Phone: 570-453-2020
  • Fax:
Mailing address:
  • Phone: 570-606-9234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOEG004023
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG004023
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: