Provider Demographics
NPI:1427885656
Name:WILEY, GARY DEWAYNE JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:DEWAYNE
Last Name:WILEY
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:4011 VIA MARINA APT 107
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-8201
Mailing Address - Country:US
Mailing Address - Phone:360-441-4248
Mailing Address - Fax:
Practice Address - Street 1:4011 VIA MARINA APT 107
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-8201
Practice Address - Country:US
Practice Address - Phone:360-441-4248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-19
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA65066363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant