Provider Demographics
NPI:1760713275
Name:WELLS, LEAH M (PA)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:M
Last Name:WELLS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:M
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1229 E SEMINOLE ST
Practice Address - Street 2:SUITE 520
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2227
Practice Address - Country:US
Practice Address - Phone:417-820-5750
Practice Address - Fax:417-820-5066
Is Sole Proprietor?:No
Enumeration Date:2010-01-22
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010001723363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicare PIN