Provider Demographics
NPI:1649368119
Name:FAIRCHILD, PATSY J (PA-C)
Entity type:Individual
Prefix:
First Name:PATSY
Middle Name:J
Last Name:FAIRCHILD
Suffix:
Gender:F
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 337
Mailing Address - Street 2:
Mailing Address - City:SCARBRO
Mailing Address - State:WV
Mailing Address - Zip Code:25917-0337
Mailing Address - Country:US
Mailing Address - Phone:304-469-2905
Mailing Address - Fax:304-465-3180
Practice Address - Street 1:221 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-1413
Practice Address - Country:US
Practice Address - Phone:304-574-3960
Practice Address - Fax:304-574-2179
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01218363A00000X
WV387363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV01218OtherLICENSE
WV3810007348Medicaid
WV001969193OtherMS BCBS
WV511820Medicare PIN
WVFA2028031Medicare PIN
WV5118201Medicare PIN
WV5119371Medicare Oscar/Certification
WV001969193OtherMS BCBS
WV3810007348Medicaid
WVQ73265Medicare UPIN
WV511821Medicare Oscar/Certification
WVPA38271Medicare PIN