Provider Demographics
NPI:1528181930
Name:SOUTHERS, GREGORY G (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:G
Last Name:SOUTHERS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 COURTHOUSE ROAD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740
Mailing Address - Country:US
Mailing Address - Phone:304-487-2297
Mailing Address - Fax:304-487-4802
Practice Address - Street 1:311 COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2421
Practice Address - Country:US
Practice Address - Phone:304-487-2297
Practice Address - Fax:304-487-4802
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV950363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP83957Medicare UPIN