Provider Demographics
NPI:1831171255
Name:WELLMAN, MARK DOUGLAS (PNP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DOUGLAS
Last Name:WELLMAN
Suffix:
Gender:M
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 ROYCE LN
Mailing Address - Street 2:
Mailing Address - City:WESTFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01886-4015
Mailing Address - Country:US
Mailing Address - Phone:978-692-9078
Mailing Address - Fax:
Practice Address - Street 1:101 THOREAU ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-2443
Practice Address - Country:US
Practice Address - Phone:978-369-9401
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA124639363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics