Provider Demographics
NPI:1639245806
Name:WILBURN, WANDA ALTHEA (MD)
Entity Type:Individual
Prefix:MISS
First Name:WANDA
Middle Name:ALTHEA
Last Name:WILBURN
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 1:19050 LENCA RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-4709
Mailing Address - Country:US
Mailing Address - Phone:760-242-4406
Mailing Address - Fax:
Practice Address - Street 1:16000 APPLE VALLEY RD
Practice Address - Street 2:SUITE C-3
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-7814
Practice Address - Country:US
Practice Address - Phone:760-946-3806
Practice Address - Fax:760-946-3809
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84253207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A842530Medicaid
CA00A842530Medicaid
CAH08746Medicare UPIN