1750313359 NPI number — DOUGLAS BRYAN WESSON ACA

Table of content: DOUGLAS BRYAN WESSON ACA (NPI 1750313359)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750313359 NPI number — DOUGLAS BRYAN WESSON ACA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WESSON
Provider First Name:
DOUGLAS
Provider Middle Name:
BRYAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ACA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750313359
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1079 EUCALYPTUS ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
MANTECA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95337-4369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-823-2107
Provider Business Mailing Address Fax Number:
209-823-0563

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1079 EUCALYPTUS ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MANTECA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95337-4369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-823-2107
Provider Business Practice Location Address Fax Number:
209-823-0563
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 237700000X , with the licence number:  HA1161 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: HA0011610 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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