Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | ME83747 | FL |
N | 207PP0204X | Pediatric Emergency Physician | ME83747 | FL |
NPI | 1760453765 |
---|---|
Provider Name | Dr. Todd Wick Wylie |
First Address | Jacksonville, FL 32231-4008 |
Second Address | Jacksonville, FL 32209-6511 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/01/2006 |
Last Update Date | 24/08/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H20256 | (02) | FL |