Provider Demographics
NPI:1992134621
Name:WYCHGRAM, ANNETTE V (NP)
Entity type:Individual
Prefix:MRS
First Name:ANNETTE
Middle Name:V
Last Name:WYCHGRAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:ANNETTE
Other - Middle Name:V
Other - Last Name:KOZIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:10700 E GEDDES AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80112-3800
Mailing Address - Country:US
Mailing Address - Phone:303-761-9190
Mailing Address - Fax:720-874-4462
Practice Address - Street 1:10700 E GEDDES AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80112-3800
Practice Address - Country:US
Practice Address - Phone:303-761-9190
Practice Address - Fax:720-874-4462
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0990852363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO13739239Medicaid
MT1992134621Medicaid
CO343332YQPGMedicare PIN
MT1992134621Medicaid