Provider Demographics
NPI:1609491091
Name:SMITH, WESLEY RYAN
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:RYAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 WOODED HAMLET CT
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-6521
Mailing Address - Country:US
Mailing Address - Phone:904-713-7920
Mailing Address - Fax:
Practice Address - Street 1:1220 CROZET AVE
Practice Address - Street 2:
Practice Address - City:CROZET
Practice Address - State:VA
Practice Address - Zip Code:22932-3163
Practice Address - Country:US
Practice Address - Phone:434-823-4307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA-23447225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant