Provider Demographics
NPI:1528075934
Name:WYVILLE, DALE VERNON (PA)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:VERNON
Last Name:WYVILLE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:39000 BOB HOPE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-341-3688
Mailing Address - Fax:760-341-8992
Practice Address - Street 1:40075 BOB HOPE DR STE A
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3945
Practice Address - Country:US
Practice Address - Phone:760-341-3688
Practice Address - Fax:760-341-8992
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2025-02-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA59022363A00000X
FLPA9103814363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant