Provider Demographics
NPI:1043254758
Name:WYSHAK, PATRICIA LYNN (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:LYNN
Last Name:WYSHAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:LAMOINE
Mailing Address - State:ME
Mailing Address - Zip Code:04605-4495
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 MADISON AVE
Practice Address - Street 2:
Practice Address - City:LAMOINE
Practice Address - State:ME
Practice Address - Zip Code:04605-4495
Practice Address - Country:US
Practice Address - Phone:207-200-1464
Practice Address - Fax:207-805-8421
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME014569207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1041904OtherAETNA
MEMD14569OtherMEDICAL LICENSE
ME336800099Medicaid
ME1041904OtherAETNA
MEMM684102Medicare PIN
MEMM6841Medicare ID - Type Unspecified