Provider Demographics
NPI:1851567093
Name:EVERSON, CAROL MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:MARIE
Last Name:EVERSON
Suffix:
Gender:F
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 1:116 MCCLELLAN RD
Mailing Address - Street 2:
Mailing Address - City:PHILIPPI
Mailing Address - State:WV
Mailing Address - Zip Code:26416-8076
Mailing Address - Country:US
Mailing Address - Phone:304-457-0063
Mailing Address - Fax:304-457-4011
Practice Address - Street 1:116 MCCLELLAN RD
Practice Address - Street 2:
Practice Address - City:PHILIPPI
Practice Address - State:WV
Practice Address - Zip Code:26416-8076
Practice Address - Country:US
Practice Address - Phone:304-457-2800
Practice Address - Fax:304-457-4011
Is Sole Proprietor?:No
Enumeration Date:2008-05-07
Last Update Date:2023-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1344207Q00000X, 363A00000X
GA007049363A00000X
WV415363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810013903Medicaid
WVPA32352Medicare PIN
WVPA32354Medicare PIN
WVPA32353Medicare PIN
WVPA32351Medicare PIN
WV3810013903Medicaid
WVPA32355Medicare PIN