Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 20A11522 | CA |
NPI | 1023349891 |
---|---|
Provider Name | Wes R Wiltse |
First Address | Vacaville, CA 95688-9494 |
Second Address | Vacaville, CA 95688-9494 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/01/2010 |
Last Update Date | 15/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
12213920 | CAQH PROVIDER NUMBER (01) | CA |
20A11522 | OSTEO MEDICAL BOARD LICENSE (01) | CA |
9796759 | AETNA PROVIDER NUMBER (01) |