Provider Demographics
NPI:1194032227
Name:TAKUBO, VICTORIA LEIGH (PA-C)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LEIGH
Last Name:TAKUBO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:LEIGH
Other - Last Name:MULLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
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:304-414-4801
Practice Address - Street 1:4610 KANAWHA AVE SW STE 401
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1367
Practice Address - Country:US
Practice Address - Phone:304-768-7368
Practice Address - Fax:304-768-1829
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01484363AM0700X
WV1484363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810024049OtherGROUP MEDICAID
WVB441OtherGROUP MEDICARE PIN
WVB441OtherGROUP MEDICARE PIN
WV1194032227Medicaid