Basic Information
| Provider Information | |||||||||
| NPI: | 1982609814 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WRYNN | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 BUTTRICK RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | LONDONDERRY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030533417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035371300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6 BUTTRICK RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | LONDONDERRY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030533417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035371300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 09/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0489P | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 30334857 | 05 | NH | MEDICAID | 222594672 | 01 | NH | GREATWEST HEALTHCARE | OTHER | 222594672 | 01 | NH | TRICARE | OTHER |