Provider Demographics
NPI:1124002068
Name:WITHERS, DAVID L II (PAC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:L
Last Name:WITHERS
Suffix:II
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 STONECREST DRIVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-9391
Mailing Address - Country:US
Mailing Address - Phone:304-525-2273
Mailing Address - Fax:304-525-2165
Practice Address - Street 1:2 STONECREST DRIVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-9391
Practice Address - Country:US
Practice Address - Phone:304-525-2273
Practice Address - Fax:304-525-2165
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01146363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0080133Medicaid
WV1124002068Medicaid
WVWV0029AOtherPTAN FOR OCCUMED, LLC
KY7100120810Medicaid