Provider Demographics
NPI:1467584532
Name:DEWRI, WAYNE T (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:T
Last Name:DEWRI
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
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 1918
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-0599
Mailing Address - Country:US
Mailing Address - Phone:909-799-7813
Mailing Address - Fax:909-796-8973
Practice Address - Street 1:10430 RHONDDA ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2881
Practice Address - Country:US
Practice Address - Phone:909-796-8206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 18316204D00000X
CAPA18316363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1467584532Medicaid
CAAU646YMedicare PIN