Healthcare Provider Details

I. General information

NPI: 1487336616
Provider Name (Legal Business Name): AUSTIN MCCLOUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 08/07/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 MAIN ST
CEREDO WV
25507-1477
US

IV. Provider business mailing address

PO BOX 1292
CEREDO WV
25507-1292
US

V. Phone/Fax

Practice location:
  • Phone: 304-544-3596
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: