Provider Demographics
NPI:1023423613
Name:PENFOLD, ADAM M (PA-C)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:M
Last Name:PENFOLD
Suffix:
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:PO BOX 392
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:WV
Mailing Address - Zip Code:26426-0392
Mailing Address - Country:US
Mailing Address - Phone:304-782-2000
Mailing Address - Fax:304-782-3102
Practice Address - Street 1:2373 W MAIN ST
Practice Address - Street 2:STE 102
Practice Address - City:SALEM
Practice Address - State:WV
Practice Address - Zip Code:26426-7515
Practice Address - Country:US
Practice Address - Phone:304-782-2000
Practice Address - Fax:304-782-3102
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2610363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2610OtherTEMPORARY STATE LICENSE