Healthcare Provider Details

I. General information

NPI: 1356559348
Provider Name (Legal Business Name): WADE M WELTON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 CENTRAL METHODIST SQ CENTRAL METHODIST UNIVERSITY
FAYETTE MO
65248-1104
US

IV. Provider business mailing address

521 COUNTY ROAD 105
FAYETTE MO
65248-8833
US

V. Phone/Fax

Practice location:
  • Phone: 660-248-6217
  • Fax: 660-248-6381
Mailing address:
  • Phone: 660-248-6217
  • Fax: 660-248-6381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number102437
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: