Basic Information
| Provider Information | |||||||||
| NPI: | 1972752954 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEMBERTON | ||||||||
| FirstName: | WESLEY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11937 US HIGHWAY 271 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757083154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038777200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11937 US HIGHWAY 271 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757083154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038777777 | ||||||||
| FaxNumber: | 9038775080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2008 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | BP10032214 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | N4658 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | N4658 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.