MEDICARE: DENNIS JON WYMAN M.D.

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	208D00000X	General Practice Physician	161632-1205	UT

General Provider Information

NPI Number	:	1316946015
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENNIS JON WYMAN M.D.

Provider Business Mailing Address
First Line	:	175 W 200 S
Second Line	:	STE 4009
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84101-1413
Country	:	US
Telephone Number	:	801-359-7756
Fax Number	:

Provider Business Practice Location Address
First Line	:	175 W 200 S
Second Line	:	STE 4009
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84101-1413
Country	:	US
Telephone Number	:	801-359-7756
Fax Number	:

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

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	10/16/2007

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