Provider Demographics
NPI:1154447977
Name:WELLS, KEVIN DALE (PA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DALE
Last Name:WELLS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4409 BLUE SAGE CT
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-3953
Mailing Address - Country:US
Mailing Address - Phone:405-701-3608
Mailing Address - Fax:405-310-5092
Practice Address - Street 1:17304 PRESTON RD
Practice Address - Street 2:SUITE 555
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-5618
Practice Address - Country:US
Practice Address - Phone:866-931-8882
Practice Address - Fax:972-934-3174
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1495207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKS11488Medicare UPIN