Provider Demographics
NPI:1821153149
Name:WYNN, ALAN HOWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:HOWARD
Last Name:WYNN
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 1:12280 PONDWATER CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-6620
Mailing Address - Country:US
Mailing Address - Phone:703-703-8198
Mailing Address - Fax:
Practice Address - Street 1:14139 POTOMAC MILLS RD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4644
Practice Address - Country:US
Practice Address - Phone:703-359-7878
Practice Address - Fax:703-490-7650
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040884207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006064043Medicaid
VA110005661Medicare ID - Type Unspecified
VA006064043Medicaid