Basic Information
| Provider Information | |||||||||
| NPI: | 1972546794 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYNN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | EUGEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 634715 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 122 12TH ST | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 24740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044877000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 11/09/2007 | ||||||||
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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 | 363L00000X | 49112 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | P00290266 | 01 | WV | MEDICARE RAILROAD | OTHER | 3810001692 | 05 | WV | MEDICAID | 001722593 | 01 | WV | BLUE CROSS | OTHER |