Provider Demographics
NPI:1548903529
Name:WELLS, SAM EVAN
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:EVAN
Last Name:WELLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9135 SKITTS MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:GA
Mailing Address - Zip Code:30527-1678
Mailing Address - Country:US
Mailing Address - Phone:706-338-4139
Mailing Address - Fax:
Practice Address - Street 1:645 MULLINAX RD
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-5618
Practice Address - Country:US
Practice Address - Phone:706-338-4139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
GA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer