Provider Demographics
NPI:1083679039
Name:WESLEY, EARL PATRICK (ATC)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:PATRICK
Last Name:WESLEY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 AMBO CIR
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-1324
Mailing Address - Country:US
Mailing Address - Phone:618-698-4017
Mailing Address - Fax:
Practice Address - Street 1:6700 CLARK RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34241-9328
Practice Address - Country:US
Practice Address - Phone:941-926-8295
Practice Address - Fax:941-923-7184
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 17742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer