Provider Demographics
NPI:1407004344
Name:WELLS, MARK R (PAC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:R
Last Name:WELLS
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Gender:M
Credentials:PAC
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Mailing Address - Street 1:208 LIFELINE RD
Mailing Address - Street 2:STE 201
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-7566
Mailing Address - Country:US
Mailing Address - Phone:570-476-6700
Mailing Address - Fax:570-476-0124
Practice Address - Street 1:208 LIFELINE RD
Practice Address - Street 2:STE 201
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-7566
Practice Address - Country:US
Practice Address - Phone:570-476-6700
Practice Address - Fax:570-476-0124
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2013-05-21
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Provider Licenses
StateLicense IDTaxonomies
PAMA053486363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical