Healthcare Provider Details

I. General information

NPI: 1780638031
Provider Name (Legal Business Name): JOHN D WYNN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 08/31/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2910 E MADISON ST STE 304
SEATTLE WA
98112-4214
US

IV. Provider business mailing address

2910 E MADISON ST STE 304
SEATTLE WA
98112-4214
US

V. Phone/Fax

Practice location:
  • Phone: 206-624-0296
  • Fax:
Mailing address:
  • Phone: 206-624-0296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00027945
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number00027945
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD00027945
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: