Basic Information
| Provider Information | |||||||||
| NPI: | 1992061436 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WYNN | ||||||||
| FirstName: | BOB | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10180 SE SUNNYSIDE RD | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970158970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032493434 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10163 SE SUNNYSIDE RD STE 490 | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970155720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8556328280 | ||||||||
| FaxNumber: | 5035134424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2012 | ||||||||
| LastUpdateDate: | 02/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | MD60739932 | WA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0804X | MD182379 | OR | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.