Provider Demographics
NPI:1003871401
Name:FAULKNER, PAMELA P (DO)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:P
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:DO
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 1030
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-1030
Mailing Address - Country:US
Mailing Address - Phone:304-431-7100
Mailing Address - Fax:304-431-7112
Practice Address - Street 1:403 12TH STREET EXT
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2300
Practice Address - Country:US
Practice Address - Phone:304-431-7100
Practice Address - Fax:304-431-7112
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1040207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0203303000Medicaid
WV0203303000Medicaid
WVMI 93194661Medicare PIN