MEDICARE: CARLIANNE WELLS PA-C

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	PA9105887	FL

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

General Provider Information

NPI Number	:	1528359460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLIANNE WELLS PA-C

Provider Business Mailing Address
First Line	:	1610 NE 1ST ST
Second Line	:	#4
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-3868
Country	:	US
Telephone Number	:	850-509-2243
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 SE 15TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-3908
Country	:	US
Telephone Number	:	954-983-1899
Fax Number	:	954-986-6846

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

Provider Enumeration Date	:	04/26/2011
Last Update Date	:	04/26/2011

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