Healthcare Provider Details

I. General information

NPI: 1285988808
Provider Name (Legal Business Name): KAREN LYNN BAILEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAREN LYNN MANTZ PA-C

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4602 MACCORKLE AVE SE 81 LINCOLN PANTHER WAY
CHARLESTON WV
25304-1848
US

IV. Provider business mailing address

4602 MACCORKLE AVE SE
CHARLESTON WV
25304-1848
US

V. Phone/Fax

Practice location:
  • Phone: 304-205-7535
  • Fax: 304-205-7536
Mailing address:
  • Phone: 304-205-7535
  • Fax: 304-205-7536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number742
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: