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General NPI Number Information
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NPI Number | 1427807692
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Entity Type | Individual
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Provider Name | WYLIE DOUGLASS NP
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Gender | Male
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Dates
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Enumeration Date | 05/18/2024
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Last Update Date | 05/18/2024
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Provider Practice Location Address
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Address Line | 500 W SAN BERNARDINO RD
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City | COVINA
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State | CA
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Zip | 91722-3797
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Country | US
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Telephone | 626-960-2326
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Fax |
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Provider Business Mailing Address
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Address Line | 2320 FAIRFIELD WAY
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City | UPLAND
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State | CA
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Zip | 91784-8609
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Country | US
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Telephone | 909-731-4413
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 95030099
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License Number State | CA
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