Provider Demographics
NPI:1831119791
Name:WELLS, JOHN W (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:WELLS
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 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5379
Mailing Address - Fax:740-446-5883
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5379
Practice Address - Fax:740-446-5883
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001045363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0113223000Medicaid
OH970013460OtherRR MEDICARE
OH310917085305OtherCARESOURCE
OH0075759Medicaid
OHPA10401Medicare PIN