Provider Demographics
NPI:1225425655
Name:WELLS, JUSTIN (IDMT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:WELLS
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1398 SURVEYOR ST
Mailing Address - Street 2:
Mailing Address - City:POPE ARMY AIRFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:28308-2710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1398 SURVEYOR ST
Practice Address - Street 2:
Practice Address - City:POPE ARMY AIRFIELD
Practice Address - State:NC
Practice Address - Zip Code:28308-2710
Practice Address - Country:US
Practice Address - Phone:910-924-5754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians