Healthcare Provider Details

I. General information

NPI: 1114254620
Provider Name (Legal Business Name): BRANDON WELLS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2009
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3502 9TH ST STE 430
LUBBOCK TX
79415-3368
US

IV. Provider business mailing address

5219 CITY BANK PKWY STE 35
LUBBOCK TX
79407-3545
US

V. Phone/Fax

Practice location:
  • Phone: 67-610-5358
  • Fax: 806-761-0534
Mailing address:
  • Phone: 68-761-0333
  • Fax: 806-782-0097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA06483
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: