=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730211061
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANE THERESA WELLS RCPA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2007
-----------------------------------------------------
Last Update Date | 07/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 SARATOGA VILLAGE BLVD STE 34
-----------------------------------------------------
City | BALLSTON SPA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12020-3738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-899-2632
-----------------------------------------------------
Fax | 518-899-6418
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 OLD SARATOGA KNOLLS LN
-----------------------------------------------------
City | SCHUYLERVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12871-1870
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-695-5535
-----------------------------------------------------
Fax | 518-899-6418
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 005885-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------