Provider Demographics
NPI:1518795574
Name:WELL, GATLUAK PUOT JR (MHP)
Entity type:Individual
Prefix:PROF
First Name:GATLUAK
Middle Name:PUOT
Last Name:WELL
Suffix:JR
Gender:M
Credentials:MHP
Other - Prefix:
Other - First Name:NIKET
Other - Middle Name:
Other - Last Name:FANHBULLEH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11 CIVIC CENTER PLZ STE 111
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-7700
Mailing Address - Country:US
Mailing Address - Phone:507-351-8071
Mailing Address - Fax:
Practice Address - Street 1:11 CIVIC CENTER PLZ STE 111
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-7700
Practice Address - Country:US
Practice Address - Phone:507-351-8071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No372600000XNursing Service Related ProvidersAdult Companion