MEDICARE: QUINTIN WYNNE PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1378054	TX
2	225100000X	Physical Therapist	070.027559	IL

General Provider Information

NPI Number	:	1396421558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	QUINTIN WYNNE PT, DPT

Provider Business Mailing Address
First Line	:	12531 WOODSTREAM DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63138-1445
Country	:	US
Telephone Number	:	314-445-9890
Fax Number	:

Provider Business Practice Location Address
First Line	:	26744 E UNIVERSITY DR STE 500
Second Line	:
City	:	AUBREY
State	:	TX
Zip	:	76227-2703
Country	:	US
Telephone Number	:	972-347-9460
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2023
Last Update Date	:	03/04/2026

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