Provider Demographics
NPI:1912095340
Name:WYDERMYER, SHEENA ROCHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:SHEENA
Middle Name:ROCHELLE
Last Name:WYDERMYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHEENA
Other - Middle Name:ROCHELLE
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-2309
Mailing Address - Country:US
Mailing Address - Phone:986-256-0161
Mailing Address - Fax:
Practice Address - Street 1:3311 ELM CREEK DR
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-1890
Practice Address - Country:US
Practice Address - Phone:986-256-0161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.27337207R00000X
TXM5981207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRES000Medicare UPIN