Provider Demographics
NPI:1972691392
Name:WELLS, PORFIRIA PEARL
Entity type:Individual
Prefix:
First Name:PORFIRIA
Middle Name:PEARL
Last Name:WELLS
Suffix:
Gender:F
Credentials:
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 39102
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78218-1102
Mailing Address - Country:US
Mailing Address - Phone:210-654-1165
Mailing Address - Fax:210-654-1178
Practice Address - Street 1:8515 GLENBLUFF
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78239
Practice Address - Country:US
Practice Address - Phone:210-654-1165
Practice Address - Fax:210-654-1178
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0103368012Medicaid
TX0958410001Medicare ID - Type Unspecified