Provider Demographics
NPI:1376834838
Name:SAN, WESLEY (MD)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:SAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 S 23RD ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1605
Mailing Address - Country:US
Mailing Address - Phone:253-272-9994
Mailing Address - Fax:253-572-0468
Practice Address - Street 1:3315 S 23RD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1605
Practice Address - Country:US
Practice Address - Phone:253-272-9994
Practice Address - Fax:253-572-0468
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-02
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60632796208VP0014X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation