Provider Demographics
NPI:1841363744
Name:WELLS, SUSAN (ANP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1723 SW MARTHA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2715
Mailing Address - Country:US
Mailing Address - Phone:907-351-8320
Mailing Address - Fax:
Practice Address - Street 1:1723 SW MARTHA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2715
Practice Address - Country:US
Practice Address - Phone:907-351-8320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK0649363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1022527Medicaid
AKK165617Medicare PIN
AKP24778Medicare UPIN