Provider Demographics
NPI:1144376732
Name:BRAGG, BILLY J
Entity type:Individual
Prefix:MR
First Name:BILLY
Middle Name:J
Last Name:BRAGG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 359A
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLARE
Mailing Address - State:WV
Mailing Address - Zip Code:26408-9731
Mailing Address - Country:US
Mailing Address - Phone:304-622-6646
Mailing Address - Fax:
Practice Address - Street 1:215 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1748
Practice Address - Country:US
Practice Address - Phone:304-842-6645
Practice Address - Fax:304-842-4909
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000554363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVS65089Medicare UPIN