Provider Demographics
NPI:1881741726
Name:WELLY, NATHANIEL (PAC)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:WELLY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S CANDY LN STE 3B
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-4120
Mailing Address - Country:US
Mailing Address - Phone:928-634-9573
Mailing Address - Fax:928-634-0135
Practice Address - Street 1:203 S CANDY LN
Practice Address - Street 2:SUITE 3B
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4120
Practice Address - Country:US
Practice Address - Phone:928-634-9573
Practice Address - Fax:928-634-0135
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1069801363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical