Provider Demographics
NPI:1235155029
Name:GONGOLA, JAYME C (PAC)
Entity Type:Individual
Prefix:MRS
First Name:JAYME
Middle Name:C
Last Name:GONGOLA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 GORMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-3181
Mailing Address - Country:US
Mailing Address - Phone:304-637-3894
Mailing Address - Fax:304-637-3435
Practice Address - Street 1:812 GORMAN AVE
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3181
Practice Address - Country:US
Practice Address - Phone:304-637-3894
Practice Address - Fax:304-637-3435
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1030351363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVGOPA10982Medicare ID - Type Unspecified
WVS57259Medicare UPIN