Provider Demographics
NPI:1881898781
Name:GATELEY, KERRY WIX (MD)
Entity type:Individual
Prefix:DR
First Name:KERRY
Middle Name:WIX
Last Name:GATELEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 THOMSON DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1009
Mailing Address - Country:US
Mailing Address - Phone:434-947-6777
Mailing Address - Fax:434-947-2338
Practice Address - Street 1:1900 THOMSON DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1009
Practice Address - Country:US
Practice Address - Phone:434-947-6777
Practice Address - Fax:434-947-2338
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21226174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004975111Medicaid