Provider Demographics
NPI:1609857341
Name:EBBA, EBBA K (MD)
Entity Type:Individual
Prefix:
First Name:EBBA
Middle Name:K
Last Name:EBBA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 GORMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-3181
Mailing Address - Country:US
Mailing Address - Phone:304-636-3300
Mailing Address - Fax:
Practice Address - Street 1:812 GORMAN AVE
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3181
Practice Address - Country:US
Practice Address - Phone:304-636-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA36724208000000X
KY50869208000000X
AL25659208000000X
KYTP229208000000X
WV32946208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F91090Medicare UPIN
F91090Medicare UPIN