Provider Demographics
NPI:1275535627
Name:WILEY, MYLEA NICHOLE (MD)
Entity Type:Individual
Prefix:MS
First Name:MYLEA
Middle Name:NICHOLE
Last Name:WILEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7035 N CHESTNUT AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-0352
Mailing Address - Country:US
Mailing Address - Phone:559-573-7260
Mailing Address - Fax:559-573-7254
Practice Address - Street 1:7035 N CHESTNUT AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-0352
Practice Address - Country:US
Practice Address - Phone:559-573-7260
Practice Address - Fax:559-573-7254
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88917207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A889170Medicaid
CA00A889171Medicare PIN
CA00A889172Medicare PIN