Provider Demographics
NPI:1497862189
Name:WYNN, TERRY A (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:A
Last Name:WYNN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14103 FENKELL ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-3214
Mailing Address - Country:US
Mailing Address - Phone:313-397-6006
Mailing Address - Fax:313-397-6368
Practice Address - Street 1:14103 FENKELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-3214
Practice Address - Country:US
Practice Address - Phone:313-397-6006
Practice Address - Fax:313-397-6368
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080116207V00000X
TN0000044902207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3042185OtherMEDICARE PTAN
MI5226815Medicaid