Provider Demographics
NPI:1699974592
Name:WYSONG, JOHN M (BS, LAC)
Entity type:Individual
Prefix:PROF
First Name:JOHN
Middle Name:M
Last Name:WYSONG
Suffix:
Gender:M
Credentials:BS, LAC
Other - Prefix:
Other - First Name:NO
Other - Middle Name:OTHER
Other - Last Name:NAME
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9145 GUILFORD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-2576
Mailing Address - Country:US
Mailing Address - Phone:410-880-4215
Mailing Address - Fax:
Practice Address - Street 1:9145 GUILFORD RD STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2576
Practice Address - Country:US
Practice Address - Phone:410-880-4215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU00962171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist