Basic Information
| Provider Information | |||||||||
| NPI: | 1750931127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | HAYES | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25590 PROSPECT AVE APT 13B | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923543145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7752321868 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1107 HIGHWAY 395 NORTH | ||||||||
| Address2: | |||||||||
| City: | GARDNERVILLE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757821500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2019 | ||||||||
| LastUpdateDate: | 09/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.