Provider Demographics
NPI:1427085760
Name:SNOW, WYNELLE R (MD)
Entity type:Individual
Prefix:
First Name:WYNELLE
Middle Name:R
Last Name:SNOW
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:PO BOX 8202
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-3202
Mailing Address - Country:US
Mailing Address - Phone:907-220-9948
Mailing Address - Fax:
Practice Address - Street 1:21 JEFFERSON ST
Practice Address - Street 2:SUITE 201
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5875
Practice Address - Country:US
Practice Address - Phone:907-220-9948
Practice Address - Fax:907-220-9947
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK12712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD60041Medicaid
AKC64799Medicare UPIN
AKMD60041Medicaid