Provider Demographics
NPI:1891430328
Name:WALNOHA, KEVIN (PR)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WALNOHA
Suffix:
Gender:M
Credentials:PR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 MCCORKLE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177-2073
Mailing Address - Country:US
Mailing Address - Phone:681-294-6861
Mailing Address - Fax:
Practice Address - Street 1:2333 MCCORKLE AVE
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-2073
Practice Address - Country:US
Practice Address - Phone:681-294-6861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-29
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV175T00000X
WV21-9136175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty