Provider Demographics
NPI:1568002509
Name:FRUTH, ALEXA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:MARIE
Last Name:FRUTH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1205
Mailing Address - Country:US
Mailing Address - Phone:304-766-9136
Mailing Address - Fax:304-766-9139
Practice Address - Street 1:607 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1205
Practice Address - Country:US
Practice Address - Phone:304-766-9136
Practice Address - Fax:304-766-9139
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV825363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant