Healthcare Provider Details

I. General information

NPI: 1558344952
Provider Name (Legal Business Name): MARK A WELLS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 HARTMAN LN STE 100
SPRINGFIELD OR
97477-1119
US

IV. Provider business mailing address

2400 HARTMAN LN
SPRINGFIELD OR
97477-1118
US

V. Phone/Fax

Practice location:
  • Phone: 541-334-3350
  • Fax: 541-746-4569
Mailing address:
  • Phone: 541-334-3350
  • Fax: 541-746-4569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00800
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00800
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: