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General NPI Number Information
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NPI Number | 1154999712
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Entity Type | Individual
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Provider Name | ANDREW WYNN
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Gender | Male
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Dates
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Enumeration Date | 06/11/2021
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Last Update Date | 08/02/2024
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Provider Practice Location Address
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Address Line | 815 S PINE ST
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City | VIVIAN
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State | LA
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Zip | 71082-3353
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Country | US
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Telephone | 318-375-3239
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 792
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City | VIVIAN
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State | LA
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Zip | 71082-0792
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Country | US
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Telephone | 318-375-3232
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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 | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 341036
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License Number State | LA
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