Provider Demographics
NPI:1780385112
Name:SANSOM, KEVIN (PA-C)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:SANSOM
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 1:1303 PETER CAVE RD
Mailing Address - Street 2:
Mailing Address - City:GENOA
Mailing Address - State:WV
Mailing Address - Zip Code:25517-7732
Mailing Address - Country:US
Mailing Address - Phone:304-633-1940
Mailing Address - Fax:
Practice Address - Street 1:1340 HAL GREER BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3804
Practice Address - Country:US
Practice Address - Phone:304-399-6727
Practice Address - Fax:304-399-6726
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2996363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0013276Medicaid
WV1780385112Medicaid
KY7100886040Medicaid