Basic Information
| Provider Information | |||||||||
| NPI: | 1922314145 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYLIE | ||||||||
| FirstName: | BLAKE | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2721 WASHINGTON STREET | ||||||||
| Address2: | |||||||||
| City: | JULIAN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607651223 | ||||||||
| FaxNumber: | 7607651278 | ||||||||
| Practice Location | |||||||||
| Address1: | 23181 VERDUGO DR STE 103A | ||||||||
| Address2: | |||||||||
| City: | LAGUNA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926531313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493661053 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2010 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A11088 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.