Provider Demographics
NPI:1699457754
Name:WELBORN, MARY (PA-S)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:WELBORN
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:FLOWERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EMT, CNA
Mailing Address - Street 1:921 S 8TH AVE STOP 8253
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-0002
Mailing Address - Country:US
Mailing Address - Phone:208-282-4726
Mailing Address - Fax:
Practice Address - Street 1:921 S 8TH AVE STOP 8253
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0002
Practice Address - Country:US
Practice Address - Phone:208-282-4726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program