Basic Information
| Provider Information | |||||||||
| NPI: | 1689605545 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WESELY | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 605 SIERRA ROSE DR | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895112060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7756895410 | ||||||||
| FaxNumber: | 7756895431 | ||||||||
| Practice Location | |||||||||
| Address1: | 605 SIERRA ROSE DR | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895112060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7756895410 | ||||||||
| FaxNumber: | 7756895431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 04/03/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 7129 | NV | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | CC9383 | 01 | NV | BLUE CROSS BLUE SHIELD | OTHER | 2016530 | 05 | NV | MEDICAID | 050057655 | 01 | NV | RAILROAD MEDICARE | OTHER |