Provider Demographics
NPI:1063585321
Name:WYNN, ERICA LARAE (MD)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:LARAE
Last Name:WYNN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14139 POTOMAC MILLS RD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-4644
Mailing Address - Country:US
Mailing Address - Phone:703-490-7740
Mailing Address - Fax:
Practice Address - Street 1:14139 POTOMAC MILLS RD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4644
Practice Address - Country:US
Practice Address - Phone:703-490-7740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236466208000000X
DCMD035456208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
5-021-162-2OtherUSMLE
I26530Medicare UPIN