Provider Demographics
NPI:1023349891
Name:WILTSE, WES R (DO)
Entity type:Individual
Prefix:
First Name:WES
Middle Name:R
Last Name:WILTSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 QUALITY DR
Mailing Address - Street 2:B36
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-9494
Mailing Address - Country:US
Mailing Address - Phone:707-684-3840
Mailing Address - Fax:
Practice Address - Street 1:1 QUALITY DR
Practice Address - Street 2:B36
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-9494
Practice Address - Country:US
Practice Address - Phone:707-684-3840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-19
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11522208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A11522OtherOSTEO MEDICAL BOARD LICENSE
9796759OtherAETNA PROVIDER NUMBER
CA12213920OtherCAQH PROVIDER NUMBER
9796759OtherAETNA PROVIDER NUMBER
CAFC633XMedicare PIN
CAFC633YMedicare PIN