Provider Demographics
NPI:1912905324
Name:WELLS, LARRY G (DPM)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:G
Last Name:WELLS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 WORTH ST
Mailing Address - Street 2:
Mailing Address - City:CORRY
Mailing Address - State:PA
Mailing Address - Zip Code:16407-1410
Mailing Address - Country:US
Mailing Address - Phone:814-663-3668
Mailing Address - Fax:814-665-4434
Practice Address - Street 1:361 WORTH ST
Practice Address - Street 2:
Practice Address - City:CORRY
Practice Address - State:PA
Practice Address - Zip Code:16407-1410
Practice Address - Country:US
Practice Address - Phone:814-663-3668
Practice Address - Fax:814-665-4434
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC2671L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA107674Medicare ID - Type Unspecified