Provider Demographics
NPI:1932461100
Name:WITZBERGER, LAWRENCE W IV (PA-C)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:W
Last Name:WITZBERGER
Suffix:IV
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 1:10 MEDICAL PARK
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-6379
Mailing Address - Country:US
Mailing Address - Phone:304-243-6534
Mailing Address - Fax:304-243-8575
Practice Address - Street 1:10 MEDICAL PARK
Practice Address - Street 2:SUITE 206
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6379
Practice Address - Country:US
Practice Address - Phone:304-243-6534
Practice Address - Fax:304-243-8575
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1636363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0350220Medicaid