Provider Demographics
NPI:1871186098
Name:SMITH, WESLEY KATHERINE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:KATHERINE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-9556
Mailing Address - Country:US
Mailing Address - Phone:919-428-4701
Mailing Address - Fax:
Practice Address - Street 1:2818 CYPRESS RIDGE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-6306
Practice Address - Country:US
Practice Address - Phone:813-712-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9114057363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant