Provider Demographics
NPI:1740265230
Name:MUNDY, DONALD P (PAC)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:P
Last Name:MUNDY
Suffix:
Gender:M
Credentials:PAC
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 100
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WV
Mailing Address - Zip Code:26807-0100
Mailing Address - Country:US
Mailing Address - Phone:304-358-2355
Mailing Address - Fax:304-358-3054
Practice Address - Street 1:314 PINE ST
Practice Address - Street 2:PENDLETON COMMUNITY CARE INC
Practice Address - City:FRANKLIN
Practice Address - State:WV
Practice Address - Zip Code:26807-0100
Practice Address - Country:US
Practice Address - Phone:304-358-2355
Practice Address - Fax:304-358-3054
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00216363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000541Medicaid
WV001714349OtherMS BCBS
WV3810000541Medicaid
WVWV3115C551Medicare PIN
WV2021403Medicare PIN
P28007Medicare UPIN