Healthcare Provider Details

I. General information

NPI: 1528654894
Provider Name (Legal Business Name): JEREMY M WYSE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2020
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LAKE VIEW DR
WAUSAU WI
54403-6799
US

IV. Provider business mailing address

1100 LAKE VIEW DR
WAUSAU WI
54403-6799
US

V. Phone/Fax

Practice location:
  • Phone: 715-848-4600
  • Fax:
Mailing address:
  • Phone: 715-848-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number261306
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: