Provider Demographics
NPI:1467195024
Name:WYNN, RYAN RANDOLPH (APRN)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:RANDOLPH
Last Name:WYNN
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SC HOUSE CALLS INC
Mailing Address - Street 2:111 DOCTORS CIRCLE
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203
Mailing Address - Country:US
Mailing Address - Phone:800-491-0909
Mailing Address - Fax:
Practice Address - Street 1:SC HOUSE CALLS INC/GA HOUSE CALLS INC
Practice Address - Street 2:125 FIRST STREET, SUITE C
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:800-491-0909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-20
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN269330363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily