Provider Demographics
NPI:1609184688
Name:SOMERVILLE, DEVON K (PA-C)
Entity Type:Individual
Prefix:
First Name:DEVON
Middle Name:K
Last Name:SOMERVILLE
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:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WV
Mailing Address - Zip Code:26807-0100
Mailing Address - Country:US
Mailing Address - Phone:304-358-2355
Mailing Address - Fax:304-358-3054
Practice Address - Street 1:82 PINE ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WV
Practice Address - Zip Code:26807-0100
Practice Address - Country:US
Practice Address - Phone:304-358-2355
Practice Address - Fax:304-358-3054
Is Sole Proprietor?:No
Enumeration Date:2010-09-23
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01507363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810021451Medicaid
WV2034952Medicare PIN
WVWV2955C551Medicare PIN
WV2034951Medicare PIN