Provider Demographics
NPI:1902033608
Name:WYNN, BRAD L (DO)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:L
Last Name:WYNN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 8TH STREET
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:ID
Mailing Address - Zip Code:83350-1527
Mailing Address - Country:US
Mailing Address - Phone:208-434-4236
Mailing Address - Fax:208-436-6038
Practice Address - Street 1:1308 8TH ST STE 1
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-1535
Practice Address - Country:US
Practice Address - Phone:208-436-4322
Practice Address - Fax:208-436-1312
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0676207Q00000X
WAOP 60289538207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1902033608Medicaid