Provider Demographics
NPI:1841261815
Name:CUMMINGS, KELLY P (PA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:P
Last Name:CUMMINGS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-2559
Mailing Address - Country:US
Mailing Address - Phone:304-422-5114
Mailing Address - Fax:304-422-5751
Practice Address - Street 1:2311 OHIO AVE
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-2559
Practice Address - Country:US
Practice Address - Phone:304-422-5114
Practice Address - Fax:304-422-5751
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA580363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000332377OtherBLUECROSS BLUESHIELD
KY95690046Medicaid
KY95690046Medicaid
S43838Medicare UPIN