Provider Demographics
NPI:1134153398
Name:WESLEY R WEDNER
Entity type:Organization
Organization Name:WESLEY R WEDNER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WES
Authorized Official - Middle Name:
Authorized Official - Last Name:WEDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-661-2088
Mailing Address - Street 1:PO BOX 988
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-0637
Mailing Address - Country:US
Mailing Address - Phone:360-734-6849
Mailing Address - Fax:
Practice Address - Street 1:17888 W BIG LAKE BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-8387
Practice Address - Country:US
Practice Address - Phone:360-734-6849
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA08655335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA649468OtherSTERLING PROVIDER NUMBER
WA7095375Medicaid
WA204961204961OtherPREMERA PROVIDER NUMBER
WA43340900O2OtherGHC PROVIDER ID NUMBER
WA204961204961OtherPREMERA PROVIDER NUMBER