Provider Demographics
NPI:1467632505
Name:RUNNION, JOHN TIMOTHY (PAC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:TIMOTHY
Last Name:RUNNION
Suffix:
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 1:645 KANAWHA AVE
Mailing Address - Street 2:
Mailing Address - City:RAINELLE
Mailing Address - State:WV
Mailing Address - Zip Code:25962-1013
Mailing Address - Country:US
Mailing Address - Phone:304-438-6188
Mailing Address - Fax:304-438-6819
Practice Address - Street 1:645 KANAWHA AVE
Practice Address - Street 2:
Practice Address - City:RAINELLE
Practice Address - State:WV
Practice Address - Zip Code:25962-1013
Practice Address - Country:US
Practice Address - Phone:304-438-6188
Practice Address - Fax:304-438-6819
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV909363A00000X
WV249363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810018844Medicaid
WVWV0652AMedicare PIN
WVRU2034451Medicare PIN