Provider Demographics
NPI:1770556896
Name:FOX, JACQUELINE GORDON (CRNA)
Entity type:Individual
Prefix:PROF
First Name:JACQUELINE
Middle Name:GORDON
Last Name:FOX
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:109 MOUNT WOOD RD
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-2632
Mailing Address - Country:US
Mailing Address - Phone:304-233-2455
Mailing Address - Fax:304-233-6073
Practice Address - Street 1:1 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6379
Practice Address - Country:US
Practice Address - Phone:304-243-3343
Practice Address - Fax:304-243-6480
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP004405B367500000X
WV36659367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0066453000Medicaid
PA101239273Medicaid
OH0943724Medicaid
OH0943724Medicaid
PAS52139Medicare UPIN