Provider Demographics
NPI:1497865711
Name:WYNN, BRUCE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:
Last Name:WYNN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:11766 HIGHWAY 27
Practice Address - Street 2:SUITE A
Practice Address - City:SUMMERVILLE
Practice Address - State:GA
Practice Address - Zip Code:30747-5989
Practice Address - Country:US
Practice Address - Phone:706-734-2878
Practice Address - Fax:706-734-2877
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-05-07
Deactivation Date:2011-11-03
Deactivation Code:
Reactivation Date:2012-07-30
Provider Licenses
StateLicense IDTaxonomies
GA001146363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003126932AMedicaid
GA003126932AMedicaid
GA202I975660Medicare PIN