Provider Demographics
NPI:1700824661
Name:STOVER, JOANNA B (PA)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:B
Last Name:STOVER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 1ST AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:NITRO
Mailing Address - State:WV
Mailing Address - Zip Code:25143-1345
Mailing Address - Country:US
Mailing Address - Phone:304-755-4797
Mailing Address - Fax:304-755-4799
Practice Address - Street 1:4111 1ST AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:NITRO
Practice Address - State:WV
Practice Address - Zip Code:25143-1345
Practice Address - Country:US
Practice Address - Phone:304-755-4797
Practice Address - Fax:304-755-4799
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01117363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95002945Medicaid
WV613154606OtherBLACK LUNG/FECA
WV001712508OtherBLUE CROSS BLUE SHIELD
WVP00372242OtherRR MEDICARE
WVSTPA13653Medicare PIN
WVPA13655Medicare PIN
WV613154606OtherBLACK LUNG/FECA
WVS21813Medicare UPIN