Basic Information
| Provider Information | |||||||||
| NPI: | 1609943935 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLS | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 217 W GEORGIA AVE | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836866811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084633234 | ||||||||
| FaxNumber: | 2084633044 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 E HAWAII AVENUE | ||||||||
| Address2: | |||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084633234 | ||||||||
| FaxNumber: | 2084633044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 12/14/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA-642 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 807594700 | 05 | ID | MEDICAID |