Healthcare Provider Details

I. General information

NPI: 1104991777
Provider Name (Legal Business Name): RENE L WELLS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 04/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 BEAVER DR BLDG C
DU BOIS PA
15801-2440
US

IV. Provider business mailing address

90 BEAVER DR BLDG C
DU BOIS PA
15801-2440
US

V. Phone/Fax

Practice location:
  • Phone: 814-317-2273
  • Fax:
Mailing address:
  • Phone: 814-317-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA051791
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOA002592
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: