Provider Demographics
NPI:1578018214
Name:SUTPHIN, MARA WRIGHT (PA-C)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:WRIGHT
Last Name:SUTPHIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:LOUISE
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7400 LYNN AVE
Mailing Address - Street 2:
Mailing Address - City:HAMLIN
Mailing Address - State:WV
Mailing Address - Zip Code:25523-1138
Mailing Address - Country:US
Mailing Address - Phone:304-824-5806
Mailing Address - Fax:304-824-5804
Practice Address - Street 1:7400 LYNN AVE
Practice Address - Street 2:
Practice Address - City:HAMLIN
Practice Address - State:WV
Practice Address - Zip Code:25523-1138
Practice Address - Country:US
Practice Address - Phone:304-824-5806
Practice Address - Fax:304-824-5804
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2772363AM0700X
WV2013363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical