Provider Demographics
NPI:1548215197
Name:WYLIE, WESLEY D (MD)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:D
Last Name:WYLIE
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 1:1027 OAKRIDGE RD S
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5615
Mailing Address - Country:US
Mailing Address - Phone:801-380-0432
Mailing Address - Fax:801-802-0108
Practice Address - Street 1:280 RIVER PARK DR
Practice Address - Street 2:SUITE 350
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-5764
Practice Address - Country:US
Practice Address - Phone:801-380-0432
Practice Address - Fax:801-802-0108
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-12076207Q00000X
UT187190-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11032Medicaid
UT11032Medicaid
UTE59809Medicare UPIN