Provider Demographics
NPI:1558414946
Name:MACSPARRAN, AMY B (PAC)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:B
Last Name:MACSPARRAN
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 1:1448 10TH AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3579
Mailing Address - Country:US
Mailing Address - Phone:304-691-6800
Mailing Address - Fax:
Practice Address - Street 1:300 CORPORATE CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560
Practice Address - Country:US
Practice Address - Phone:304-691-6800
Practice Address - Fax:304-691-6751
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002685363A00000X
WV1783363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1558414946Medicaid
WVB441OtherGROUP MEDICARE
WV3810024049OtherGROUP MEDICAID
WVWV3849B441Medicare PIN