Healthcare Provider Details

I. General information

NPI: 1184642829
Provider Name (Legal Business Name): PROFESSIONAL ENDOCRINOLOGY ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 10/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 LAIDLEY ST STE 507 PROFESSIONAL ENDOCRINOLOGY ASSOCIATES, PLLC
CHARLESTON WV
25301-1682
US

IV. Provider business mailing address

PO BOX 3466
CHARLESTON WV
25334-3466
US

V. Phone/Fax

Practice location:
  • Phone: 304-720-1963
  • Fax: 304-720-1966
Mailing address:
  • Phone: 304-720-1963
  • Fax: 304-720-1966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: SAMAR R. SANKARI
Title or Position: OWNER, PHYSICIAN, MANAGING MEMBER
Credential: M.D.
Phone: 304-720-1963