Provider Demographics
NPI:1871298844
Name:LISME, WESLY J
Entity type:Individual
Prefix:
First Name:WESLY
Middle Name:J
Last Name:LISME
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 LAKE EMERALD DR APT 202
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33309-6205
Mailing Address - Country:US
Mailing Address - Phone:954-479-2244
Mailing Address - Fax:
Practice Address - Street 1:1426 BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-6110
Practice Address - Country:US
Practice Address - Phone:813-684-8020
Practice Address - Fax:813-684-8206
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1367PA363A00000X, 363AM0700X
FLTPPA452363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical