MEDICARE: JAMES-TYLER DYLAN WINNARD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	363A00000X	Physician Assistant	PA17077	TX

General Provider Information

NPI Number	:	1225727837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES-TYLER DYLAN WINNARD

Provider Business Mailing Address
First Line	:	1701 N CLASSEN BLVD APT 309
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73106-6009
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1701 N CLASSEN BLVD APT 309
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73106-6009
Country	:	US
Telephone Number	:	580-222-9434
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2023
Last Update Date	:	09/25/2023

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