Provider Demographics
NPI:1427496835
Name:WELBORN, JOHN L IV (FNP-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:WELBORN
Suffix:IV
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 W BARNEY ST
Mailing Address - Street 2:
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642-1040
Mailing Address - Country:US
Mailing Address - Phone:315-287-1000
Mailing Address - Fax:315-261-6025
Practice Address - Street 1:8 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:NY
Practice Address - Zip Code:13635
Practice Address - Country:US
Practice Address - Phone:315-562-1055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF337418363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF337418OtherLICENSE