MEDICARE: WYMAN COOK JR.

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	172A00000X	Driver	050335946	GA

General Provider Information

NPI Number	:	1629882360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WYMAN COOK JR.

Provider Business Mailing Address
First Line	:	9073 ALDBURY DR
Second Line	:
City	:	LOCUST GROVE
State	:	GA
Zip	:	30248-2456
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9073 ALDBURY DR
Second Line	:
City	:	LOCUST GROVE
State	:	GA
Zip	:	30248-2456
Country	:	US
Telephone Number	:	770-480-3604
Fax Number	:

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

Provider Enumeration Date	:	02/04/2025
Last Update Date	:	02/04/2025

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