Provider Demographics
NPI:1730171620
Name:WYMAN, EDWIN MACKENZIE (MD)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:MACKENZIE
Last Name:WYMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MAC
Other - Middle Name:
Other - Last Name:WYMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1280 N MILDRED RD
Mailing Address - Street 2:STE 1
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-2212
Mailing Address - Country:US
Mailing Address - Phone:970-565-9500
Mailing Address - Fax:970-565-9538
Practice Address - Street 1:1280 N MILDRED RD
Practice Address - Street 2:STE 1
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-2212
Practice Address - Country:US
Practice Address - Phone:970-565-9500
Practice Address - Fax:970-565-9538
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31702207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
COF28043Medicare UPIN
CO475008Medicare PIN