Provider Demographics
NPI:1760771794
Name:WYLIE, JAMES DEREK (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DEREK
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 1:1888 SUN PEAK DR
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-6718
Mailing Address - Country:US
Mailing Address - Phone:216-333-5836
Mailing Address - Fax:
Practice Address - Street 1:5848 S FASHION BLVD
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6157
Practice Address - Country:US
Practice Address - Phone:801-314-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT55564207XX0005X
MA270960207XX0005X
UT8438015-1205207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine