Provider Demographics
NPI:1811287444
Name:WYMER, JONATHAN A (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:A
Last Name:WYMER
Suffix:
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22380 COUNTY ROAD 75 NW
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-9707
Mailing Address - Country:US
Mailing Address - Phone:763-516-7789
Mailing Address - Fax:
Practice Address - Street 1:101 EGRET BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-5077
Practice Address - Country:US
Practice Address - Phone:763-742-2147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-16
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 190844-4163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse