Basic Information
| Provider Information | |||||||||
| NPI: | 1871186098 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | WESLEY | ||||||||
| MiddleName: | KATHERINE | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 712 TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956309556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194284701 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2818 CYPRESS RIDGE BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | WESLEY CHAPEL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335446306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137125700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2021 | ||||||||
| LastUpdateDate: | 02/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9114057 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.