Provider Demographics
NPI:1720021447
Name:WEBB, IRA TED JR (PA-C)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:TED
Last Name:WEBB
Suffix:JR
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 1:200 12TH STREET EXT
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 WESTWOOD CMN
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605-2031
Practice Address - Country:US
Practice Address - Phone:276-235-6232
Practice Address - Fax:276-250-5117
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV762363A00000X
VA0110840810363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001920236OtherBLUE SHIELD
WVP00023341OtherRRGA
WVP00023341OtherMEDICARE RAILROAD
S83233Medicare UPIN
WVP00023341OtherMEDICARE RAILROAD