MEDICARE: ROY WELLS JR. PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0550030649	VT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	00049928	OTHER	VT	BCBS

General Provider Information

NPI Number	:	1215939079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROY WELLS JR. PAC

Provider Business Mailing Address
First Line	:	PO BOX 235
Second Line	:
City	:	FAIRFAX
State	:	VT
Zip	:	05454-0235
Country	:	US
Telephone Number	:	802-868-2454
Fax Number	:	802-868-2461

Provider Business Practice Location Address
First Line	:	45 CHURCH ST
Second Line	:
City	:	SWANTON
State	:	VT
Zip	:	05488-1434
Country	:	US
Telephone Number	:	802-868-2454
Fax Number	:	802-868-2461

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	10/15/2007

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