Provider Demographics
NPI:1093719650
Name:WYNN, WANDA L (PA)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:L
Last Name:WYNN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4210 PIONEER WOODS DR
Mailing Address - Street 2:STE A
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-7561
Mailing Address - Country:US
Mailing Address - Phone:402-488-4321
Mailing Address - Fax:402-488-4355
Practice Address - Street 1:4210 PIONEER WOODS DR
Practice Address - Street 2:STE A
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-7561
Practice Address - Country:US
Practice Address - Phone:402-488-4321
Practice Address - Fax:402-488-4355
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA00961363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAS10541Medicare UPIN
IA47697Medicare ID - Type Unspecified
IA47697Medicare PIN