Provider Demographics
NPI:1770704249
Name:WYNAR, BRUCE R
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:R
Last Name:WYNAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5520 173RD PL SW
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98037-3034
Mailing Address - Country:US
Mailing Address - Phone:425-787-1235
Mailing Address - Fax:
Practice Address - Street 1:521 WALL ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98121-1524
Practice Address - Country:US
Practice Address - Phone:800-543-9323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004022363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP28307Medicare UPIN