Provider Demographics
NPI:1730211061
Name:WELLS, DIANE THERESA (RCPA)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:THERESA
Last Name:WELLS
Suffix:
Gender:F
Credentials:RCPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3 OLD SARATOGA KNOLLS LN
Mailing Address - Street 2:
Mailing Address - City:SCHUYLERVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12871-1870
Mailing Address - Country:US
Mailing Address - Phone:518-695-5535
Mailing Address - Fax:518-899-6418
Practice Address - Street 1:100 SARATOGA VILLAGE BLVD STE 34
Practice Address - Street 2:
Practice Address - City:BALLSTON SPA
Practice Address - State:NY
Practice Address - Zip Code:12020-3738
Practice Address - Country:US
Practice Address - Phone:518-899-2632
Practice Address - Fax:518-899-6418
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005885-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYDD3936Medicare ID - Type Unspecified
NYS43856Medicare UPIN