Provider Demographics
NPI:1225212624
Name:WYMER, ANTOINETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTOINETTE
Middle Name:
Last Name:WYMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TONI
Other - Middle Name:
Other - Last Name:WYMER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:201 EXECUTIVE PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1503
Mailing Address - Country:US
Mailing Address - Phone:336-774-9000
Mailing Address - Fax:336-774-9012
Practice Address - Street 1:201 EXECUTIVE PARK BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1503
Practice Address - Country:US
Practice Address - Phone:336-774-9000
Practice Address - Fax:336-774-9012
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-20
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33772207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCB91479Medicare UPIN
NC2141013CMedicare PIN