Provider Demographics
NPI:1326753971
Name:WELLS, MICHAEL (PA-C, RT (R))
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WELLS
Suffix:
Gender:M
Credentials:PA-C, RT (R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 HELENE ST
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-1623
Mailing Address - Country:US
Mailing Address - Phone:516-796-8406
Mailing Address - Fax:
Practice Address - Street 1:2310 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-2035
Practice Address - Country:US
Practice Address - Phone:516-595-0206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical