Provider Demographics
NPI:1700274339
Name:WELTON, LEVI
Entity Type:Individual
Prefix:
First Name:LEVI
Middle Name:
Last Name:WELTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 EASTERN PKWY
Mailing Address - Street 2:APT 4
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-3520
Mailing Address - Country:US
Mailing Address - Phone:929-278-6050
Mailing Address - Fax:
Practice Address - Street 1:856 EASTERN PKWY
Practice Address - Street 2:APT 4
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-3520
Practice Address - Country:US
Practice Address - Phone:929-278-6050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018273363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant