Provider Demographics
NPI:1730533076
Name:WELLS, WESLEY (CRNA)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:WELLS
Suffix:
Gender:M
Credentials:CRNA
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 507
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-0507
Mailing Address - Country:US
Mailing Address - Phone:678-690-8332
Mailing Address - Fax:678-992-1463
Practice Address - Street 1:2710 S RIFE MEDICAL LN
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758
Practice Address - Country:US
Practice Address - Phone:479-338-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-22
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014006195163W00000X
ARC003159367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200790330AMedicaid
AR5BZ36OtherBCBS ARKANSAS
ARP02077944OtherRAILROAD
MO910070613Medicaid
AR215761001Medicaid