Healthcare Provider Details

I. General information

NPI: 1316159676
Provider Name (Legal Business Name): JASON TERRANCE WELLS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 N BROAD ST
WINDER GA
30680-2150
US

IV. Provider business mailing address

PO BOX 742616
ATLANTA GA
30374-2616
US

V. Phone/Fax

Practice location:
  • Phone: 770-867-3400
  • Fax:
Mailing address:
  • Phone: 770-219-8420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301110953
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number81174
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: