Provider Demographics
NPI:1649743196
Name:WELCH, ROBERT (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WELCH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1055 N 500 W
Practice Address - Street 2:STE 112 BLDG C
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-812-4624
Practice Address - Fax:801-812-4699
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT13121909-1206363A00000X
NVPA2070363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant