Provider Demographics
NPI:1215939079
Name:WELLS, ROY JR (PAC)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:
Last Name:WELLS
Suffix:JR
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:PO BOX 235
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VT
Mailing Address - Zip Code:05454-0235
Mailing Address - Country:US
Mailing Address - Phone:802-868-2454
Mailing Address - Fax:802-868-2461
Practice Address - Street 1:45 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SWANTON
Practice Address - State:VT
Practice Address - Zip Code:05488-1434
Practice Address - Country:US
Practice Address - Phone:802-868-2454
Practice Address - Fax:802-868-2461
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550030649363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0002358Medicaid
VT00049928OtherBCBS
VTAP1404Medicare ID - Type Unspecified
VTP00202315Medicare PIN
VTVN0879Medicare PIN
VT0002358Medicaid