Provider Demographics
NPI:1639111768
Name:QUISENBERRY, JERRY A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:A
Last Name:QUISENBERRY
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 1:7400 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:304-824-5885
Practice Address - Street 1:471 MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WV
Practice Address - Zip Code:25130-1223
Practice Address - Country:US
Practice Address - Phone:304-369-5170
Practice Address - Fax:304-369-0946
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV867363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P43378Medicare UPIN
WVQUPA18012Medicare ID - Type UnspecifiedMWV