Healthcare Provider Details

I. General information

NPI: 1720083785
Provider Name (Legal Business Name): CLYDE W WOODYARD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 01/26/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2726 ELECTRIC RD
ROANOKE VA
24018-3528
US

IV. Provider business mailing address

PO BOX 21435
ROANOKE VA
24018-0551
US

V. Phone/Fax

Practice location:
  • Phone: 540-772-4448
  • Fax: 540-772-0410
Mailing address:
  • Phone: 540-772-4448
  • Fax: 540-772-0410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110840258
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: