Provider Demographics
NPI:1962448621
Name:WYNNE, SUSAN P (OD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:P
Last Name:WYNNE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15600 REDMOND WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-3862
Mailing Address - Country:US
Mailing Address - Phone:425-882-2923
Mailing Address - Fax:425-869-5063
Practice Address - Street 1:15600 REDMOND WAY STE 300
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3862
Practice Address - Country:US
Practice Address - Phone:425-882-2923
Practice Address - Fax:425-968-8930
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3012152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2022135Medicaid
WAT10525Medicare UPIN
WAAB00439Medicare ID - Type Unspecified