Provider Demographics
NPI:1568230001
Name:PROVINES, MICHAEL WYNN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WYNN
Last Name:PROVINES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 DUNBERRY LN
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1603
Mailing Address - Country:US
Mailing Address - Phone:954-496-2260
Mailing Address - Fax:954-833-2066
Practice Address - Street 1:4201 DUNBERRY LN
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1603
Practice Address - Country:US
Practice Address - Phone:954-496-2260
Practice Address - Fax:954-833-2066
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220655-01207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine