Provider Demographics
NPI:1457475840
Name:WELLS, THOMAS TARRY (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:TARRY
Last Name:WELLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3290
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-3290
Mailing Address - Country:US
Mailing Address - Phone:907-235-9030
Mailing Address - Fax:
Practice Address - Street 1:4300 BARTLETT ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7005
Practice Address - Country:US
Practice Address - Phone:907-234-0362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK26462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD26463Medicaid
030ZGBCNBMedicare ID - Type Unspecified
AKMD26463Medicaid