Provider Demographics
NPI:1164149019
Name:GILMORE, SAMUEL COPELAND (PA)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:COPELAND
Last Name:GILMORE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 QUINCE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKINGHAM
Mailing Address - State:VA
Mailing Address - Zip Code:22801-5318
Mailing Address - Country:US
Mailing Address - Phone:304-488-5588
Mailing Address - Fax:
Practice Address - Street 1:306 STANAFORD RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3142
Practice Address - Country:US
Practice Address - Phone:304-255-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-21
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1228984363A00000X
WV1178133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant