Provider Demographics
NPI:1972535367
Name:TOLENTINO, WILFRIDO T JR (PA C)
Entity Type:Individual
Prefix:
First Name:WILFRIDO
Middle Name:T
Last Name:TOLENTINO
Suffix:JR
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 1:1717 HARPER RD FL 3
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3373
Mailing Address - Country:US
Mailing Address - Phone:304-254-3131
Mailing Address - Fax:
Practice Address - Street 1:1717 HARPER RD FL 3
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3373
Practice Address - Country:US
Practice Address - Phone:304-254-3131
Practice Address - Fax:304-254-3037
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV690363AS0400X
WV00690363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0011253000Medicaid
WVP00116053OtherRR MEDICARE
WVCI5175OtherRR MEDICARE
WVP96204Medicare UPIN
WVCI5175OtherRR MEDICARE
WV0011253000Medicaid
WV5544650001Medicare NSC
WVCI5175OtherRR MEDICARE
WV5544650001Medicare NSC
WV55075562100OtherWORKERS COMPENSATION WV