Provider Demographics
NPI:1801625421
Name:WYNN, ELLIS LAMAR IV (SRNA)
Entity type:Individual
Prefix:
First Name:ELLIS
Middle Name:LAMAR
Last Name:WYNN
Suffix:IV
Gender:M
Credentials:SRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1636 S CASTLE STONE SQ
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59106-9724
Mailing Address - Country:US
Mailing Address - Phone:229-854-9517
Mailing Address - Fax:
Practice Address - Street 1:1139 PICKET FENCE DR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-9158
Practice Address - Country:US
Practice Address - Phone:229-854-9517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-31
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN286537163W00000X
MT267591367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse