Provider Demographics
NPI:1568438539
Name:GITELMAN, LARRY R (ADVANCED RN PRACT)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:R
Last Name:GITELMAN
Suffix:
Gender:M
Credentials:ADVANCED RN PRACT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6230
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-0722
Mailing Address - Country:US
Mailing Address - Phone:304-242-7106
Mailing Address - Fax:304-242-7108
Practice Address - Street 1:310 AMERICAN WAY STE A
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-4083
Practice Address - Country:US
Practice Address - Phone:304-797-6410
Practice Address - Fax:304-797-6320
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP005783L363L00000X
WVAPRN59184363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7102381000Medicaid
GINP76001Medicare ID - Type Unspecified
P05368Medicare UPIN