Basic Information
| Provider Information | |||||||||
| NPI: | 1902033608 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WYNN | ||||||||
| FirstName: | BRAD | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1308 8TH ST | ||||||||
| Address2: | STE 1 | ||||||||
| City: | RUPERT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833501535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084364322 | ||||||||
| FaxNumber: | 2084361312 | ||||||||
| Practice Location | |||||||||
| Address1: | 2550 ADDISON AVE E | ||||||||
| Address2: | SUITE B | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833016749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088147700 | ||||||||
| FaxNumber: | 2089339301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2009 | ||||||||
| LastUpdateDate: | 01/02/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | O-0676 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OP 60289538 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1902033608 | 05 | ID | MEDICAID |