Healthcare Provider Details

I. General information

NPI: 1770296626
Provider Name (Legal Business Name): TRENT WYNN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2023
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21756 STATE ROAD 54 STE 102
LUTZ FL
33549-2905
US

IV. Provider business mailing address

21756 STATE ROAD 54 STE 102
LUTZ FL
33549-2905
US

V. Phone/Fax

Practice location:
  • Phone: 727-475-5540
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTT39819
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: