Provider Demographics
NPI:1245670488
Name:WELLS, KESHIA D (PA)
Entity type:Individual
Prefix:
First Name:KESHIA
Middle Name:D
Last Name:WELLS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 VINEHAVEN DR NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2438
Mailing Address - Country:US
Mailing Address - Phone:704-783-1840
Mailing Address - Fax:
Practice Address - Street 1:1070 VINEHAVEN DR NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2438
Practice Address - Country:US
Practice Address - Phone:704-783-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04250363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical