Provider Demographics
NPI:1609097898
Name:VANDERLAN, WESLEY BLAKE (MD)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:BLAKE
Last Name:VANDERLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WESLEY B.
Other - Middle Name:BLAKE
Other - Last Name:VON RIEDENAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3320 THOMASVILLE RD STE 302
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-7971
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3320 THOMASVILLE RD STE 302
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-7971
Practice Address - Country:US
Practice Address - Phone:504-391-8320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14789207PE0004X, 208600000X, 2086S0102X, 2086S0127X
GA19302086S0102X
FLME1154952086S0102X
IDMC-26912086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117675Medicaid
MS00117675Medicaid
MS302I022583Medicare PIN