Healthcare Provider Details

I. General information

NPI: 1245881663
Provider Name (Legal Business Name): KATHRYN MICHELLE WELLS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2019
Last Update Date: 05/03/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 LANDING DR
NORTH AUGUSTA SC
29841-5403
US

IV. Provider business mailing address

105 LANDING DR
NORTH AUGUSTA SC
29841-5403
US

V. Phone/Fax

Practice location:
  • Phone: 704-488-3958
  • Fax:
Mailing address:
  • Phone: 704-488-3958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10210
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: