Provider Demographics
NPI:1124205505
Name:WELLS, ANTHONY SHANE (AT,C)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:SHANE
Last Name:WELLS
Suffix:
Gender:M
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12340 STATE ROUTE 104
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-8968
Mailing Address - Country:US
Mailing Address - Phone:740-703-1283
Mailing Address - Fax:740-941-5163
Practice Address - Street 1:12340 STATE ROUTE 104
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-8968
Practice Address - Country:US
Practice Address - Phone:740-703-1283
Practice Address - Fax:740-941-5163
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10682255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer