1134126410 NPI number — TINA TRAHAN WELLS MD

Table of content: TINA TRAHAN WELLS MD (NPI 1134126410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134126410 NPI number — TINA TRAHAN WELLS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WELLS
Provider First Name:
TINA
Provider Middle Name:
TRAHAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134126410
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4869
Provider Second Line Business Mailing Address:
DEPARTMENT NUMBER 237
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77210-4869
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-744-1141
Provider Business Mailing Address Fax Number:
847-537-4866

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17520 OLD JEFFERSON HWY
Provider Second Line Business Practice Location Address:
STE. B
Provider Business Practice Location Address City Name:
PRAIRIEVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70769-3929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-673-8983
Provider Business Practice Location Address Fax Number:
225-677-8983
Provider Enumeration Date:
07/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  D22798 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1664987 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080137693 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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