Provider Demographics
NPI:1992757637
Name:TRUESDALE, WESLEY SCOTT (CP)
Entity type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:SCOTT
Last Name:TRUESDALE
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1471
Mailing Address - Street 2:106 MEDICAL DRIVE
Mailing Address - City:ELIZ CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909
Mailing Address - Country:US
Mailing Address - Phone:252-338-3002
Mailing Address - Fax:252-338-2902
Practice Address - Street 1:106 MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:ELIZ CITY
Practice Address - State:NC
Practice Address - Zip Code:27909
Practice Address - Country:US
Practice Address - Phone:252-338-3002
Practice Address - Fax:252-338-2902
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCP001787224P00000X
NC332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0482POtherBCBS
VA384410OtherBCBS
VA9190511Medicaid
NC7701327Medicaid
NC7701327Medicaid