Provider Demographics
NPI:1720192487
Name:WILEY, WENDY (PA)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:WILEY
Suffix:
Gender:F
Credentials:PA
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 1449
Mailing Address - Street 2:
Mailing Address - City:GUERNEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95446-1449
Mailing Address - Country:US
Mailing Address - Phone:707-869-5977
Mailing Address - Fax:707-869-5983
Practice Address - Street 1:3802 MAIN ST
Practice Address - Street 2:
Practice Address - City:OCCIDENTAL
Practice Address - State:CA
Practice Address - Zip Code:95465
Practice Address - Country:US
Practice Address - Phone:707-874-2444
Practice Address - Fax:707-874-1664
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11243363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA11243OtherSTATE LICENSE NUMBER
CA1598768962Medicaid
CAS09877Medicare UPIN
CA551803Medicare Oscar/Certification