Provider Demographics
NPI:1811042815
Name:LOTT, WYNNE KENDRA (PA-C)
Entity Type:Individual
Prefix:
First Name:WYNNE
Middle Name:KENDRA
Last Name:LOTT
Suffix:
Gender:F
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 1:4 S TALLAHASSEE ST STE 4
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:GA
Mailing Address - Zip Code:31539-6136
Mailing Address - Country:US
Mailing Address - Phone:912-699-6570
Mailing Address - Fax:912-354-7569
Practice Address - Street 1:4 S TALLAHASSEE ST STE 4
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:GA
Practice Address - Zip Code:31539-6136
Practice Address - Country:US
Practice Address - Phone:912-699-6570
Practice Address - Fax:912-699-6572
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003905363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q21006Medicare UPIN