Healthcare Provider Details

I. General information

NPI: 1376834838
Provider Name (Legal Business Name): WESLEY SAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2011
Last Update Date: 11/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3315 S 23RD ST SUITE 200
TACOMA WA
98405-1605
US

IV. Provider business mailing address

3315 S 23RD ST SUITE 200
TACOMA WA
98405-1605
US

V. Phone/Fax

Practice location:
  • Phone: 253-272-9994
  • Fax: 253-572-0468
Mailing address:
  • Phone: 253-272-9994
  • Fax: 253-572-0468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberMD60632796
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD60632796
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: