Provider Demographics
NPI:1992738652
Name:WESLEY, GINA MARIE (OD)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:WESLEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 HIGHWAY 55 STE 300
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55340-9771
Mailing Address - Country:US
Mailing Address - Phone:763-478-3505
Mailing Address - Fax:763-478-2727
Practice Address - Street 1:922 HIGHWAY 55 STE 300
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:MN
Practice Address - Zip Code:55340-9771
Practice Address - Country:US
Practice Address - Phone:763-478-3505
Practice Address - Fax:763-478-2727
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3061152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist