MEDICARE: DR. MICHAEL LEE WYNN MD

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	208600000X	Surgery Physician	006398000	CA

General Provider Information

NPI Number	:	1285673996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL LEE WYNN MD

Provider Business Mailing Address
First Line	:	325 DISTEL CIR
Second Line	:
City	:	LOS ALTOS
State	:	CA
Zip	:	94022-1408
Country	:	US
Telephone Number	:	925-277-1055
Fax Number	:	925-277-1915

Provider Business Practice Location Address
First Line	:	5601 NORRIS CANYON RD
Second Line	:	STE 100
City	:	SAN RAMON
State	:	CA
Zip	:	94583-5407
Country	:	US
Telephone Number	:	925-277-1055
Fax Number	:	925-277-1915

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

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	06/03/2020

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