Basic Information
| Provider Information | |||||||||
| NPI: | 1407004344 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WELLS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 208 LIFELINE RD | ||||||||
| Address2: | STE 201 | ||||||||
| City: | STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183607566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704766700 | ||||||||
| FaxNumber: | 5704760124 | ||||||||
| Practice Location | |||||||||
| Address1: | 208 LIFELINE RD | ||||||||
| Address2: | STE 201 | ||||||||
| City: | STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183607566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704766700 | ||||||||
| FaxNumber: | 5704760124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2008 | ||||||||
| LastUpdateDate: | 05/21/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | MA053486 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.