Provider Demographics
NPI:1164672945
Name:WELLS, SUSAN BAILEY (PA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:BAILEY
Last Name:WELLS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:STE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:65 INTERNATIONAL DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4816
Practice Address - Country:US
Practice Address - Phone:864-987-7000
Practice Address - Fax:864-672-7852
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1336363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAPPROVEDMedicaid
SCAPPROVEDMedicaid