Provider Demographics
NPI:1497048904
Name:SPROUSE, GRETCHEN DAWN EGBERT (MD)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:DAWN EGBERT
Last Name:SPROUSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:DAWN
Other - Last Name:EGBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:203 E 4TH AVE
Mailing Address - Street 2:UHP WOMEN'S HEALTH & FAMILY MEDICINE
Mailing Address - City:RANSON
Mailing Address - State:WV
Mailing Address - Zip Code:25438-1617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:203 E 4TH AVE
Practice Address - Street 2:UHP WOMEN'S HEALTH & FAMILY MEDICINE
Practice Address - City:RANSON
Practice Address - State:WV
Practice Address - Zip Code:25438-1617
Practice Address - Country:US
Practice Address - Phone:304-725-6343
Practice Address - Fax:304-725-5523
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV26397207Q00000X
KYR2647390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCJ3570280Medicare PIN
NC186YTOtherBCBS NC
NC1497048904Medicaid