Provider Demographics
NPI:1396359808
Name:WYNSEN, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:WYNSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 RICHMOND SQ STE 200
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-5117
Mailing Address - Country:US
Mailing Address - Phone:401-433-4172
Mailing Address - Fax:401-433-0612
Practice Address - Street 1:4859 NIXON PARK DR
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-8106
Practice Address - Country:US
Practice Address - Phone:513-653-2911
Practice Address - Fax:513-275-5750
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT03314225100000X
OHPT020687225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist