Provider Demographics
NPI:1710320437
Name:WETMORE, DUSTIN K (PA-C)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:K
Last Name:WETMORE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5510
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94581-0510
Mailing Address - Country:US
Mailing Address - Phone:707-252-9660
Mailing Address - Fax:707-258-2780
Practice Address - Street 1:121 SOTOYOME ST STE 201
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405
Practice Address - Country:US
Practice Address - Phone:707-308-3101
Practice Address - Fax:707-546-4062
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22901363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA22901OtherPHYSICIAN ASSISTANT