Healthcare Provider Details

I. General information

NPI: 1003961095
Provider Name (Legal Business Name): WESLEY DALE ANDERSON L.S.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4384 N CYPRESS AVE
ODESSA TX
79764-9376
US

IV. Provider business mailing address

4384 N CYPRESS AVE
ODESSA TX
79764-9376
US

V. Phone/Fax

Practice location:
  • Phone: 432-385-7979
  • Fax: 432-385-7979
Mailing address:
  • Phone: 432-385-7979
  • Fax: 432-385-7979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberSA00001
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: