Individual
VANDER M WYNN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
5309 WATERVIEW DR, NORTH PORT, FL 34291-8032
(239) 261-1158
(239) 261-4232
Mailing address
5309 WATERVIEW DR, NORTH PORT, FL 34291-8032
(239) 261-1158
(239) 261-4232
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
075180
GA
207L00000X
Anesthesiology Physician
281372
NY
207L00000X
Anesthesiology Physician
Primary
ME66148
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
050029800
RAILROAD MEDICARE
—
01
—
25438
BLUE CROSS BLUE SHIELD OF FL
FL
05
—
375454500
—
FL
Enumeration date
08/31/2006
Last updated
03/07/2023
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