Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 164759 | NY |
NPI | 1184805764 |
---|---|
Provider Name | Mr. Dejuan Lamont Wynn |
First Address | New York, NY 10026-1320 |
Second Address | New York, NY 10026-1320 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/11/2007 |
Last Update Date | 24/11/2007 |