Healthcare Provider Details

I. General information

NPI: 1457344541
Provider Name (Legal Business Name): CAROL H WYSHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROL D HATCH

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 12/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E 5TH AVE
SPOKANE WA
99202-1334
US

IV. Provider business mailing address

PO BOX 3649
SPOKANE WA
99220-3649
US

V. Phone/Fax

Practice location:
  • Phone: 509-838-2531
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberMD00029515
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: