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General NPI Number Information
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NPI Number | 1043231699
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Entity Type | Individual
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Provider Name | LINDA WYNNE RPAC
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Gender | Female
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Dates
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Enumeration Date | 07/21/2006
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Last Update Date | 09/16/2014
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Provider Practice Location Address
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Address Line | 815 HALLOCK AVE
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-1220
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Country | US
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Telephone | 631-331-7267
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Fax |
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Provider Business Mailing Address
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Address Line | 22 SILAS WOODS RD
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City | MANORVILLE
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State | NY
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Zip | 11949-3053
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 006266-1
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License Number State | NY
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