Provider Demographics
NPI:1801254412
Name:DOTY, JACK III (PA)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:DOTY
Suffix:III
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 1:7400 LYNN AVE
Mailing Address - Street 2:
Mailing Address - City:HAMLIN
Mailing Address - State:WV
Mailing Address - Zip Code:25523-1138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5027 HELENA AVE
Practice Address - Street 2:
Practice Address - City:DELBARTON
Practice Address - State:WV
Practice Address - Zip Code:25670-1301
Practice Address - Country:US
Practice Address - Phone:304-475-1761
Practice Address - Fax:304-475-1762
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1970363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV6221AMedicare PIN
WVWV6621B663Medicare PIN
WVWV6621FMedicare PIN
WVWV6621GMedicare PIN
WVP01674857Medicare Oscar/Certification
WVWV6621DMedicare PIN
WVWB6621B662Medicare PIN
WVWV6621CMedicare PIN
WVWV6621ABMedicare PIN
WVWV6621HMedicare PIN
WVWV6621EMedicare PIN