Provider Demographics
NPI:1821302605
Name:ANTHOU, DAVID ADAM (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ADAM
Last Name:ANTHOU
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 1:9404 CARRIAGE LN
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-7834
Mailing Address - Country:US
Mailing Address - Phone:304-366-1111
Mailing Address - Fax:
Practice Address - Street 1:9404 CARRIAGE LN
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-7834
Practice Address - Country:US
Practice Address - Phone:304-366-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105538363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant