Provider Demographics
NPI:1720083785
Name:WOODYARD, CLYDE W (PA-C)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:W
Last Name:WOODYARD
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 21435
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-0551
Mailing Address - Country:US
Mailing Address - Phone:540-772-4448
Mailing Address - Fax:540-772-0410
Practice Address - Street 1:2726 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3528
Practice Address - Country:US
Practice Address - Phone:540-772-4448
Practice Address - Fax:540-772-0410
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA242488OtherANTHEM
541839718OtherC&O
WV54183971800OtherWV MEDICARE
200026OtherLUNG
VA006404995Medicaid
VA541839718042OtherBS MOUNTAIN STATE
WV541839718043OtherBS MOUNTAIN STATE
WV54183971800OtherWV MEDICARE
1519679Medicare ID - Type UnspecifiedUMWA
VA541839718042OtherBS MOUNTAIN STATE
WV541839718043OtherBS MOUNTAIN STATE
541839718OtherC&O