Individual
JACK WINFRED WYLIE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
450 S WILLARD ST, SUITE 105, COTTONWOOD, AZ 86326-6743
(928) 634-1112
(928) 634-1117
Mailing address
1200 N BEAVER ST, PAYER CREDENTIALING, FLAGSTAFF, AZ 86001-3118
(928) 773-2559
(928) 213-6292
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
23100
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
212134
—
AZ
Enumeration date
06/17/2006
Last updated
03/16/2017
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