Provider Demographics
NPI:1396418497
Name:WILWAND, MCKELLE S (PA-C)
Entity Type:Individual
Prefix:
First Name:MCKELLE
Middle Name:S
Last Name:WILWAND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1730
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1058
Mailing Address - Country:US
Mailing Address - Phone:760-568-2684
Mailing Address - Fax:
Practice Address - Street 1:39000 BOB HOPE DR, HARRY AND DIANE RINKER BLG
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-568-2684
Practice Address - Fax:760-837-2238
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60521363A00000X
CAPA65021363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty