Healthcare Provider Details

I. General information

NPI: 1861031023
Provider Name (Legal Business Name): MARK RYAN WYLIE FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2020
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 SHOPPERS WAY
BRUNSWICK GA
31525-0530
US

IV. Provider business mailing address

106 SHOPPERS WAY STE 115
BRUNSWICK GA
31525-0522
US

V. Phone/Fax

Practice location:
  • Phone: 912-265-7660
  • Fax:
Mailing address:
  • Phone: 912-265-7660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN260231
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: