| Doctor Name: | MR. DEREK R WYNN |
| NPI Number: | 1043689441 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PA |
| License Number: | PA-1276 |
| Business Practice Address: | 607 W Main Street Grangeville, ID - 83530 |
| Business Phone Number: | 2089831700 |
| Business Fax Number: | 2089834665 |
| Mailing Address: | 607 W Main St, GRANGEVILLE |
| State: | ID |
| Postal Code: | 835301345 |
| Phone Number: | 2089831700 |
| Fax Number: | 2089834665 |
| NPI Enumeration Date: | 09/16/2015 |
| NPI Last Update Date: | 09/16/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | PA-1276 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ID |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |