MEDICARE: DR. JOHN D WYNN MD

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	207R00000X	Internal Medicine Physician	MD00027945	WA
2	2084P0015X	Psychosomatic Medicine Physician	00027945	WA
3	2084P0800X	Psychiatry Physician	MD00027945	WA

General Provider Information

NPI Number	:	1780638031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN D WYNN MD

Provider Business Mailing Address
First Line	:	2910 E MADISON ST STE 304
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98112-4214
Country	:	US
Telephone Number	:	206-624-0296
Fax Number	:

Provider Business Practice Location Address
First Line	:	2910 E MADISON ST STE 304
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98112-4214
Country	:	US
Telephone Number	:	206-624-0296
Fax Number	:

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

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	08/31/2022

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