Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204F00000X | Transplant Surgeon | 2007008872 | MO |
NPI | 1134331382 |
---|---|
Provider Name | Dr. Jason Reid Wellen |
First Address | Saint Louis, MO 63110-1010 |
Second Address | Saint Louis, MO 63110-1003 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2007 |
Last Update Date | 12/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
207356809 | (05) | MO |