Provider Demographics
NPI:1003961095
Name:ANDERSON, WESLEY DALE (LSA)
Entity Type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:DALE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4384 N CYPRESS AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79764-9376
Mailing Address - Country:US
Mailing Address - Phone:432-385-7979
Mailing Address - Fax:432-385-7979
Practice Address - Street 1:4384 N CYPRESS AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79764-9376
Practice Address - Country:US
Practice Address - Phone:432-385-7979
Practice Address - Fax:432-385-7979
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00001246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist