Provider Demographics
NPI:1710953922
Name:VERNON, ROBERT ALAN (PA C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALAN
Last Name:VERNON
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:215 DON KNOTTS BLVD
Mailing Address - Street 2:STE 130
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501
Mailing Address - Country:US
Mailing Address - Phone:304-291-3627
Mailing Address - Fax:304-598-3630
Practice Address - Street 1:215 DON KNOTTS BLVD
Practice Address - Street 2:STE 130
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501
Practice Address - Country:US
Practice Address - Phone:304-291-3627
Practice Address - Fax:304-598-3630
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WV00918363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P83350Medicare UPIN