Provider Demographics
NPI:1043255052
Name:WYLIE, JACK WINFRED (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:WINFRED
Last Name:WYLIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:PAYER CREDENTIALING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-773-2559
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:450 S WILLARD ST
Practice Address - Street 2:SUITE 105
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-6743
Practice Address - Country:US
Practice Address - Phone:928-634-1112
Practice Address - Fax:928-634-1117
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23100207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ212134Medicaid
F61342Medicare UPIN
AZZ190852Medicare PIN