Provider Demographics
NPI:1831812338
Name:WYNN, DAWSON TATE (ATS)
Entity type:Individual
Prefix:
First Name:DAWSON
Middle Name:TATE
Last Name:WYNN
Suffix:
Gender:M
Credentials:ATS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-2744
Mailing Address - Country:US
Mailing Address - Phone:573-453-6034
Mailing Address - Fax:
Practice Address - Street 1:1102 W CENTER ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560-2744
Practice Address - Country:US
Practice Address - Phone:573-453-6034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer