Provider Demographics
NPI:1689776247
Name:WELLMAN, AMBER MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:MARIE
Last Name:WELLMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:MARIE
Other - Last Name:BLAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3957 E COVELL RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6909
Mailing Address - Country:US
Mailing Address - Phone:405-285-7246
Mailing Address - Fax:405-285-7546
Practice Address - Street 1:3957 E COVELL RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6909
Practice Address - Country:US
Practice Address - Phone:405-285-7246
Practice Address - Fax:405-285-7546
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA1394363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEQ14209Medicare UPIN
NE277607Medicare ID - Type UnspecifiedISSUED NE, NOT USED OK