Provider Demographics
NPI:1356365480
Name:WYNN, RICHARD THOMAS (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:THOMAS
Last Name:WYNN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:16147 LANCASTER HWY
Mailing Address - Street 2:STE 140
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-4782
Mailing Address - Country:US
Mailing Address - Phone:704-208-4134
Mailing Address - Fax:704-248-7845
Practice Address - Street 1:16147 LANCASTER HWY
Practice Address - Street 2:SUITE 140
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-4782
Practice Address - Country:US
Practice Address - Phone:704-208-4134
Practice Address - Fax:704-248-7845
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC9500282207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89592OtherBSBC
NC1356365480Medicaid
NC8989592Medicaid
NC89592OtherBSBC
NC1356365480Medicaid