Provider Demographics
NPI:1972955276
Name:MITCHELL, WESLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:MITCHELL
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 1:2595 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-5905
Mailing Address - Country:US
Mailing Address - Phone:901-260-8500
Mailing Address - Fax:901-260-8598
Practice Address - Street 1:3362 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38109-2944
Practice Address - Country:US
Practice Address - Phone:901-701-2510
Practice Address - Fax:901-701-2516
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2877363A00000X
363AM0700X
TN3080363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical