Provider Demographics
NPI:1649326273
Name:WELLMAN, GARY N (PA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:N
Last Name:WELLMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-0125
Mailing Address - Country:US
Mailing Address - Phone:425-344-7250
Mailing Address - Fax:
Practice Address - Street 1:301 116TH AVE SE STE 105
Practice Address - Street 2:SUITE #250
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-6482
Practice Address - Country:US
Practice Address - Phone:425-454-1919
Practice Address - Fax:425-454-7018
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAPA10001347363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical