Healthcare Provider Details

I. General information

NPI: 1073652335
Provider Name (Legal Business Name): DONALD HOLCOMB II PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MORRIS ST STE 300
CHARLESTON WV
25301-1853
US

IV. Provider business mailing address

415 MORRIS ST 300
CHARLESTON WV
25301-1853
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-6441
  • Fax: 304-388-6445
Mailing address:
  • Phone: 304-388-6441
  • Fax: 304-388-6445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number00973
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number973
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: