Provider Demographics
NPI:1730173915
Name:GREGORY, CARLA J (PA)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:J
Last Name:GREGORY
Suffix:
Gender:F
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:PO BOX 35
Mailing Address - Street 2:
Mailing Address - City:NEWBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26410-0035
Mailing Address - Country:US
Mailing Address - Phone:304-892-2828
Mailing Address - Fax:304-892-2927
Practice Address - Street 1:725 NORTH PIKE STREET
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WV
Practice Address - Zip Code:26354-1270
Practice Address - Country:US
Practice Address - Phone:304-265-4909
Practice Address - Fax:304-266-4915
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV499363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810002614Medicaid
WV2019674Medicare PIN
S52567Medicare UPIN
WV2019673Medicare PIN
WV3810002614Medicaid
WVP00125803Medicare PIN
WV2019671Medicare PIN
WV2019661Medicare PIN
WV2019651Medicare PIN