Basic Information
| Provider Information | |||||||||
| NPI: | 1730533076 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WELLS | ||||||||
| FirstName: | WESLEY | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 507 | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727450507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6786908332 | ||||||||
| FaxNumber: | 6789921463 | ||||||||
| Practice Location | |||||||||
| Address1: | 2710 S RIFE MEDICAL LN | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793388000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2016 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 2014006195 | MO | N | Nursing Service Providers | Registered Nurse | 367500000X | C003159 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 200790330A | 05 | OK | MEDICAID | 5BZ36 | 01 | AR | BCBS ARKANSAS | OTHER | P02077944 | 01 | AR | RAILROAD | OTHER | 910070613 | 05 | MO | MEDICAID | 215761001 | 05 | AR | MEDICAID |