Healthcare Provider Details

I. General information

NPI: 1922209600
Provider Name (Legal Business Name): SCOTT NICHOLAS WELLE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16601 N 40TH ST STE 204
PHOENIX AZ
85032-3356
US

IV. Provider business mailing address

16601 N 40TH ST STE 204
PHOENIX AZ
85032-3356
US

V. Phone/Fax

Practice location:
  • Phone: 602-633-3721
  • Fax: 602-953-5466
Mailing address:
  • Phone: 602-633-3721
  • Fax: 602-953-5466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number005622
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: