Healthcare Provider Details

I. General information

NPI: 1003264359
Provider Name (Legal Business Name): WYATT STEBBINS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2016
Last Update Date: 05/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 GREENLEY RD
SONORA CA
95370-5200
US

IV. Provider business mailing address

PO BOX 4685
SONORA CA
95370-1685
US

V. Phone/Fax

Practice location:
  • Phone: 209-532-1326
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: