Provider Demographics
NPI:1043967383
Name:WILAND, WINONA LILI (PA-C)
Entity type:Individual
Prefix:
First Name:WINONA
Middle Name:LILI
Last Name:WILAND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 VICTORIA AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-3962
Mailing Address - Country:US
Mailing Address - Phone:310-913-6787
Mailing Address - Fax:
Practice Address - Street 1:5405 OBERLIN DR FL 2
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1700
Practice Address - Country:US
Practice Address - Phone:858-909-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA60745363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant