Provider Demographics
NPI:1609943935
Name:WELLS, ERIC N (PA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:N
Last Name:WELLS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 W GEORGIA AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6811
Mailing Address - Country:US
Mailing Address - Phone:208-463-3234
Mailing Address - Fax:208-463-3044
Practice Address - Street 1:215 E HAWAII AVENUE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686
Practice Address - Country:US
Practice Address - Phone:208-463-3234
Practice Address - Fax:208-463-3044
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-642363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807594700Medicaid
ID807594700Medicaid