Provider Demographics
NPI:1114181898
Name:WYNN, RANDALL LAMAR (PT)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:LAMAR
Last Name:WYNN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 REGAL KNOLLS DRIVE
Mailing Address - Street 2:
Mailing Address - City:MILLS RIVER
Mailing Address - State:NC
Mailing Address - Zip Code:28759
Mailing Address - Country:US
Mailing Address - Phone:828-684-5213
Mailing Address - Fax:
Practice Address - Street 1:600 CAROLINA VILLAGE RD
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28792-2892
Practice Address - Country:US
Practice Address - Phone:828-692-6275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4948225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist