Provider Demographics
NPI:1528437357
Name:GOTHAM, JORY CHRISTOPHER JAMES (PA-C)
Entity type:Individual
Prefix:MR
First Name:JORY
Middle Name:CHRISTOPHER JAMES
Last Name:GOTHAM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:
Practice Address - Street 1:4607 MACCORKLE AVE SW STE 401
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1364
Practice Address - Country:US
Practice Address - Phone:304-414-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV819363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1154871OtherPA-C
64058OtherNATA