Provider Demographics
NPI:1750517330
Name:WELLS, JASON M (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:WELLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4619 KENNY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-2779
Mailing Address - Country:US
Mailing Address - Phone:614-457-8180
Mailing Address - Fax:
Practice Address - Street 1:600 GRESHAM DR
Practice Address - Street 2:PATHOLOGY DEPARTMENT
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-3221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT195871207ZC0006X
UT8566738-1205207ZP0102X
VA0101260185207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1750517330Medicaid
VAVVK982AMedicare PIN