Provider Demographics
NPI:1629799630
Name:WYNNE, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WYNNE
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 1:312 SHOREWARD DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-5148
Mailing Address - Country:US
Mailing Address - Phone:203-446-1113
Mailing Address - Fax:
Practice Address - Street 1:2150 PENNSYLVANIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-3201
Practice Address - Country:US
Practice Address - Phone:202-741-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program