Provider Demographics
NPI:1629231147
Name:WILEY, CHRISTI LYNN (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTI
Middle Name:LYNN
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:PO BOX 10488
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0488
Mailing Address - Country:US
Mailing Address - Phone:888-344-9111
Mailing Address - Fax:909-335-7130
Practice Address - Street 1:17051 SIERRA LAKES PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1274
Practice Address - Country:US
Practice Address - Phone:909-428-2040
Practice Address - Fax:909-428-2191
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA98378207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1629231147Medicaid
CAA98378OtherCA MED LIC LICENSE
CA1174760953Medicaid
CA1518136787Medicaid
CA1174760953Medicaid
CACD331Medicare PIN
CAZZZ01339ZMedicare PIN
CABJ854Medicare PIN