Provider Demographics
NPI:1851587414
Name:WOOLWINE, VICTORIA ANN (PA)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ANN
Last Name:WOOLWINE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:ROCK CAVE
Mailing Address - State:WV
Mailing Address - Zip Code:26234-0217
Mailing Address - Country:US
Mailing Address - Phone:304-924-6262
Mailing Address - Fax:304-924-5460
Practice Address - Street 1:ROUTE 4 & 20 S. INTERSECTION
Practice Address - Street 2:
Practice Address - City:ROCK CAVE
Practice Address - State:WV
Practice Address - Zip Code:26234
Practice Address - Country:US
Practice Address - Phone:304-924-6262
Practice Address - Fax:304-924-5460
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810011341Medicaid
WV2029271Medicare PIN
WV2030143Medicare PIN
WV3810011341Medicaid
WV2030142Medicare PIN