Provider Demographics
NPI:1467642496
Name:WYNESKI, HOLLY K (MD)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:K
Last Name:WYNESKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:128 E MILLTOWN RD STE 205
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-1276
Mailing Address - Country:US
Mailing Address - Phone:330-685-9920
Mailing Address - Fax:
Practice Address - Street 1:128 E MILLTOWN RD STE 205
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691
Practice Address - Country:US
Practice Address - Phone:330-685-9920
Practice Address - Fax:330-685-9286
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35090889208800000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2842526Medicaid
OHWY4233281Medicare PIN