Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213ES0131X | Foot Surgery | O1555 | MD |
NPI | 1083840524 |
---|---|
Provider Name | Jacob Wynes |
First Address | Baltimore, MD 21207 |
Second Address | Baltimore, MD 21207 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2009 |
Last Update Date | 14/03/2019 |