Healthcare Provider Details

I. General information

NPI: 1205990843
Provider Name (Legal Business Name): SHAWN W WYNN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 03/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 VALLEY VIEW DR
MOLINE IL
61265-6194
US

IV. Provider business mailing address

520 VALLEY VIEW DR
MOLINE IL
61265-6194
US

V. Phone/Fax

Practice location:
  • Phone: 309-762-3621
  • Fax: 309-762-3690
Mailing address:
  • Phone: 309-762-3621
  • Fax: 309-762-3690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036116081
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number37086
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number036116081
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number37086
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: