Healthcare Provider Details

I. General information

NPI: 1528075934
Provider Name (Legal Business Name): DALE VERNON WYVILLE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40075 BOB HOPE DR STE A
RANCHO MIRAGE CA
92270-3945
US

IV. Provider business mailing address

39000 BOB HOPE DR
RANCHO MIRAGE CA
92270-3221
US

V. Phone/Fax

Practice location:
  • Phone: 760-341-3688
  • Fax: 760-341-8992
Mailing address:
  • Phone: 760-341-3688
  • Fax: 760-341-8992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number59022
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: