Healthcare Provider Details

I. General information

NPI: 1942336052
Provider Name (Legal Business Name): PHILIP ANDERS WIXOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2007
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6037 PRICE AVE
MCCLELLAN CA
95652-2400
US

IV. Provider business mailing address

1779 KEESLER CIR
SUISUN CITY CA
94585-6326
US

V. Phone/Fax

Practice location:
  • Phone: 279-345-3580
  • Fax: 916-643-7708
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101240912
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: