Provider Demographics
NPI:1083006753
Name:WORMINGTON, WESLEY NATHAN (PA-C)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:NATHAN
Last Name:WORMINGTON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:777 RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1522
Mailing Address - Country:US
Mailing Address - Phone:651-447-3755
Mailing Address - Fax:651-444-8923
Practice Address - Street 1:777 RAYMOND AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1522
Practice Address - Country:US
Practice Address - Phone:651-447-3755
Practice Address - Fax:651-444-8923
Is Sole Proprietor?:No
Enumeration Date:2015-03-04
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015006472363A00000X
MN14197363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant