Provider Demographics
NPI:1134126410
Name:WELLS, TINA TRAHAN (MD)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:TRAHAN
Last Name:WELLS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4869
Mailing Address - Street 2:DEPARTMENT NUMBER 237
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4869
Mailing Address - Country:US
Mailing Address - Phone:877-744-1141
Mailing Address - Fax:847-537-4866
Practice Address - Street 1:17520 OLD JEFFERSON HWY
Practice Address - Street 2:STE. B
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-3929
Practice Address - Country:US
Practice Address - Phone:225-673-8983
Practice Address - Fax:225-677-8983
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAD22798207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1664987Medicaid
LA080137693OtherRAILROAD MEDICARE
LA5Y141C362Medicare PIN
LA1664987Medicaid