Provider Demographics
NPI:1801844303
Name:YOUSAF, MOHAMMAD (PAC)
Entity Type:Individual
Prefix:MR
First Name:MOHAMMAD
Middle Name:
Last Name:YOUSAF
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:
Practice Address - Street 1:1097 FLEDDERJOHN RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-4208
Practice Address - Country:US
Practice Address - Phone:304-345-3627
Practice Address - Fax:304-346-4440
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV484363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810024049OtherMEDICAID-GROUP
WVB441OtherMEDICARE-GROUP
WV3810024049OtherMEDICAID-GROUP
WVWV4804B441Medicare PIN
WVP01662313OtherRAILROAD MEDICARE