Healthcare Provider Details

I. General information

NPI: 1467584532
Provider Name (Legal Business Name): WAYNE T. DEWRI PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 12/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10430 RHONDDA ST
REDLANDS CA
92374-2881
US

IV. Provider business mailing address

PO BOX 1918
LOMA LINDA CA
92354-0599
US

V. Phone/Fax

Practice location:
  • Phone: 909-796-8206
  • Fax:
Mailing address:
  • Phone: 909-799-7813
  • Fax: 909-796-8973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberPA 18316
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18316
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: