Healthcare Provider Details

I. General information

NPI: 1548215197
Provider Name (Legal Business Name): WESLEY D WYLIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 RIVER PARK DR SUITE 350
PROVO UT
84604-5764
US

IV. Provider business mailing address

1027 OAKRIDGE RD S
PARK CITY UT
84098-5615
US

V. Phone/Fax

Practice location:
  • Phone: 801-380-0432
  • Fax: 801-802-0108
Mailing address:
  • Phone: 801-380-0432
  • Fax: 801-802-0108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number187190-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberM-12076
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-12076
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: