Healthcare Provider Details

I. General information

NPI: 1548376148
Provider Name (Legal Business Name): WYNNE MEDICAL CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 FALLS BLVD S
WYNNE AR
72396-3514
US

IV. Provider business mailing address

PO BOX 158
WYNNE AR
72396-0158
US

V. Phone/Fax

Practice location:
  • Phone: 870-238-2321
  • Fax: 870-238-0114
Mailing address:
  • Phone: 870-238-2321
  • Fax: 870-238-0114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. SHELIA BURROW
Title or Position: OFFICE MANAGER
Credential:
Phone: 870-238-2321