Provider Demographics
NPI:1770908907
Name:SUMRALL, WESLEY D (PA-C)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:D
Last Name:SUMRALL
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 1:2601 CHERRY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-4208
Mailing Address - Country:US
Mailing Address - Phone:360-415-9110
Mailing Address - Fax:
Practice Address - Street 1:2601 CHERRY AVE STE 200
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-4208
Practice Address - Country:US
Practice Address - Phone:360-415-9110
Practice Address - Fax:253-582-1617
Is Sole Proprietor?:No
Enumeration Date:2014-02-25
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA 60420918363AM0700X
WAPA60420918363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical