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General NPI Number Information
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NPI Number | 1255308102
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Entity Type | Individual
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Provider Name | JOHN R WYNN M.D.
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Gender | Male
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Dates
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Enumeration Date | 02/28/2006
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Last Update Date | 06/26/2019
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Provider Practice Location Address
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Address Line | 171 N 400 W C-12
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City | OREM
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State | UT
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Zip | 84057-1909
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Country | US
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Telephone | 801-224-4550
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Fax | 801-224-1057
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Provider Business Mailing Address
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Address Line | 171 N 400 W C-12
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City | OREM
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State | UT
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Zip | 84057-1909
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Country | US
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Telephone | 801-224-4550
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Fax | 801-224-1057
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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 | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 2746431205
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License Number State | UT
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