Provider Demographics
NPI:1043689441
Name:WYNN, DEREK R (PA)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:R
Last Name:WYNN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-1345
Mailing Address - Country:US
Mailing Address - Phone:208-983-1700
Mailing Address - Fax:208-983-4665
Practice Address - Street 1:607 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530
Practice Address - Country:US
Practice Address - Phone:208-983-1700
Practice Address - Fax:208-983-4665
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1276363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID131315Medicare PIN
ID1750336608Medicare UPIN
ID131315Medicare Oscar/Certification