Provider Demographics
NPI:1659579480
Name:WELLS, SHAWN JEFFREY (PTA)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:JEFFREY
Last Name:WELLS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 CRAPO ST
Mailing Address - Street 2:APT #1
Mailing Address - City:BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02324
Mailing Address - Country:US
Mailing Address - Phone:508-807-1399
Mailing Address - Fax:
Practice Address - Street 1:26 ASYLUM ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757
Practice Address - Country:US
Practice Address - Phone:508-473-0400
Practice Address - Fax:508-473-3440
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8080225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9723251Medicaid
MAPT0165Medicare ID - Type UnspecifiedGROUP