Provider Demographics
NPI:1003929712
Name:WYS, KENNETH GLEN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:GLEN
Last Name:WYS
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 1:47111 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-6739
Mailing Address - Country:US
Mailing Address - Phone:760-347-6191
Mailing Address - Fax:760-775-8017
Practice Address - Street 1:47111 MONROE ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-6739
Practice Address - Country:US
Practice Address - Phone:760-347-6191
Practice Address - Fax:760-775-8017
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64344207L00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA64344EMedicare PIN