Provider Demographics
NPI:1689778722
Name:WYNN, MICHAEL PRESTON (MD MPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PRESTON
Last Name:WYNN
Suffix:
Gender:M
Credentials:MD MPH
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:36000 DARNALL LOOP
Mailing Address - Street 2:CARL R DARNALL ARMY MEDICAL CENTER
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10625 W PARMER LN
Practice Address - Street 2:D400
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78717-4007
Practice Address - Country:US
Practice Address - Phone:512-733-9400
Practice Address - Fax:512-733-0400
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2008-07-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA040819207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA040819OtherLICENSE NUMBER