Provider Demographics
NPI:1770297749
Name:GWINN, JAMES OSCAR (PRSS)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:OSCAR
Last Name:GWINN
Suffix:
Gender:M
Credentials:PRSS
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 46
Mailing Address - Street 2:
Mailing Address - City:MABSCOTT
Mailing Address - State:WV
Mailing Address - Zip Code:25871-0046
Mailing Address - Country:US
Mailing Address - Phone:304-731-0925
Mailing Address - Fax:
Practice Address - Street 1:345 PRINCE ST STE 1
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-4515
Practice Address - Country:US
Practice Address - Phone:304-731-0925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22-9307175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1326521840Medicaid