Healthcare Provider Details

I. General information

NPI: 1053062984
Provider Name (Legal Business Name): ALYSSA GREGORY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 3RD AVE
HUNTINGTON WV
25703-1225
US

IV. Provider business mailing address

31 SAFFRON CT
CULLODEN WV
25510-7242
US

V. Phone/Fax

Practice location:
  • Phone: 304-691-1880
  • Fax:
Mailing address:
  • Phone: 304-638-1693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.008227RX
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2771
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number2771
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: