Provider Demographics
NPI:1700113412
Name:BULLOUGH, KIESHA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KIESHA
Middle Name:MARIE
Last Name:BULLOUGH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIESHA
Other - Middle Name:MARIE
Other - Last Name:WINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 OAKMOUND RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-9398
Mailing Address - Country:US
Mailing Address - Phone:304-623-6330
Mailing Address - Fax:304-623-6220
Practice Address - Street 1:700 OAKMOUND RD
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-9398
Practice Address - Country:US
Practice Address - Phone:304-623-6330
Practice Address - Fax:304-623-6220
Is Sole Proprietor?:No
Enumeration Date:2009-11-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01444363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810016314Medicaid
WVPA34603Medicare PIN
WV3810016314Medicaid
WVPA34605Medicare PIN
WVPA34601Medicare PIN
WVPA34604Medicare PIN