Healthcare Provider Details

I. General information

NPI: 1376550855
Provider Name (Legal Business Name): GREGORY SCOTT WYNN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 W 800 N STE 300
OREM UT
84057-6300
US

IV. Provider business mailing address

716 W 800 N STE 300
OREM UT
84057-6300
US

V. Phone/Fax

Practice location:
  • Phone: 801-224-0421
  • Fax: 801-224-0821
Mailing address:
  • Phone: 801-224-0421
  • Fax: 801-224-0821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number97-341832-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: