Provider Demographics
NPI:1104991777
Name:WELLS, RENE L (PA-C)
Entity type:Individual
Prefix:
First Name:RENE
Middle Name:L
Last Name:WELLS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 BEAVER DR BLDG C
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-2440
Mailing Address - Country:US
Mailing Address - Phone:814-317-2273
Mailing Address - Fax:
Practice Address - Street 1:90 BEAVER DR BLDG C
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-2440
Practice Address - Country:US
Practice Address - Phone:814-317-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA002592207Q00000X
PAMA051791363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018251700002Medicaid
PA2078210OtherBLUE SHIELD
PAV0075DOtherUPMC
PA61854OtherGEISINGER
PA200674ZB2DMedicare PIN
PAV0075DOtherUPMC