Basic Information
| Provider Information | |||||||||
| NPI: | 1275526360 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WYSHAM | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 873010 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986873010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608822778 | ||||||||
| FaxNumber: | 3606041771 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 NE 87TH AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986641913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608823662 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 11/07/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | MD00029442 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | MD00029442 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 8135832 | 05 | WA | MEDICAID |