Healthcare Provider Details

I. General information

NPI: 1710320437
Provider Name (Legal Business Name): DUSTIN K WETMORE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 SOTOYOME ST STE 201
SANTA ROSA CA
95405
US

IV. Provider business mailing address

PO BOX 5510
NAPA CA
94581-0510
US

V. Phone/Fax

Practice location:
  • Phone: 707-308-3101
  • Fax: 707-546-4062
Mailing address:
  • Phone: 707-252-9660
  • Fax: 707-258-2780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA22901
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: