Provider Demographics
NPI:1265524144
Name:MAHAN, WESLEY S JR (CRNA)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:S
Last Name:MAHAN
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5606 WESTSHORE DR
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-3032
Mailing Address - Country:US
Mailing Address - Phone:727-846-0065
Mailing Address - Fax:
Practice Address - Street 1:5606 WESTSHORE DR
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-3032
Practice Address - Country:US
Practice Address - Phone:727-846-0065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1549802367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG0087OtherBLUE CROSS BLUE SHIELD
FLP00029835OtherRAILROAD MEDICARE
FL033670000Medicaid
FLG0087OtherBLUE CROSS BLUE SHIELD