Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207P00000X | Emergency Physician | 37295 | KY |
Y | 207PE0004X | Emergency Medical Services | 057269 | GA |
NPI | 1063478139 |
---|---|
Provider Name | Brett Wynn |
First Address | Carrollton, GA 30117-4647 |
Second Address | Carrollton, GA 30117-3818 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/04/2006 |
Last Update Date | 08/06/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
918889310A | (05) | GA |
H30896 | (02) | GA |