Healthcare Provider Details

I. General information

NPI: 1447792395
Provider Name (Legal Business Name): WESLEY SMITH DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 COUNTRY CLUB RD STE 210B
EUGENE OR
97401-6091
US

IV. Provider business mailing address

16083 SW UPPER BOONES FERRY RD
TIGARD OR
97224-7736
US

V. Phone/Fax

Practice location:
  • Phone: 541-242-4171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number61978
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: