Provider Demographics
NPI:1023256799
Name:WELLS, PATRICIA RAQUEL (PTA)
Entity type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:RAQUEL
Last Name:WELLS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:HEMINGWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29554-9191
Mailing Address - Country:US
Mailing Address - Phone:843-558-4830
Mailing Address - Fax:843-558-7752
Practice Address - Street 1:401 N MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:HEMINGWAY
Practice Address - State:SC
Practice Address - Zip Code:29554-9191
Practice Address - Country:US
Practice Address - Phone:843-558-4830
Practice Address - Fax:843-558-7752
Is Sole Proprietor?:No
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2311225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC426611Medicare PIN