Provider Demographics
NPI:1548432974
Name:PHOENIX, WYNTER NIGEL (MD)
Entity type:Individual
Prefix:
First Name:WYNTER
Middle Name:NIGEL
Last Name:PHOENIX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 PLEASANT GROVE BLVD
Mailing Address - Street 2:STE 120
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678
Mailing Address - Country:US
Mailing Address - Phone:916-791-8346
Mailing Address - Fax:916-791-8833
Practice Address - Street 1:1211 PLEASANT GROVE BLVD
Practice Address - Street 2:STE 120
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678
Practice Address - Country:US
Practice Address - Phone:916-791-8346
Practice Address - Fax:916-791-8833
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12345208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1548432974OtherNPI
NV1548432974Medicaid