Provider Demographics
NPI:1669077137
Name:KO, WESLEY W
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:W
Last Name:KO
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 1:18882 MASTERSON PL
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94552-5082
Mailing Address - Country:US
Mailing Address - Phone:510-359-8012
Mailing Address - Fax:
Practice Address - Street 1:2850 SEVENTH ST STE 100
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94710-2703
Practice Address - Country:US
Practice Address - Phone:510-845-5170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299405225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist