Healthcare Provider Details

I. General information

NPI: 1376150755
Provider Name (Legal Business Name): NATHANIEL LEWIS RAINEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 GROSSCUP AVE
DUNBAR WV
25064-3120
US

IV. Provider business mailing address

1100 GROSSCUP AVE
DUNBAR WV
25064-3120
US

V. Phone/Fax

Practice location:
  • Phone: 304-768-8811
  • Fax: 304-768-4072
Mailing address:
  • Phone: 304-768-8811
  • Fax: 304-768-4072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2452
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: