Basic Information
| Provider Information | |||||||||
| NPI: | 1821153149 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYNN | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | HOWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 12280 PONDWATER CT | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221926620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037038198 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14139 POTOMAC MILLS RD | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221924644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033597878 | ||||||||
| FaxNumber: | 7034907650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 06/01/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101040884 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 006064043 | 05 | VA | MEDICAID |