Healthcare Provider Details

I. General information

NPI: 1821060849
Provider Name (Legal Business Name): MARK LEE WELLS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 W GRAND AVE
CHICKASHA OK
73018-5862
US

IV. Provider business mailing address

411 W GRAND AVE
CHICKASHA OK
73018-5862
US

V. Phone/Fax

Practice location:
  • Phone: 405-224-0053
  • Fax:
Mailing address:
  • Phone: 405-224-0053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1099
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: