Provider Demographics
NPI:1356770887
Name:WYNN, JACLYN (PA-C)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:WYNN
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:PO BOX 140764
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32614-0764
Mailing Address - Country:US
Mailing Address - Phone:352-332-0030
Mailing Address - Fax:
Practice Address - Street 1:6440 W NEWBERRY RD
Practice Address - Street 2:STE 401
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4381
Practice Address - Country:US
Practice Address - Phone:352-332-0030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107604363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant