Healthcare Provider Details

I. General information

NPI: 1356374110
Provider Name (Legal Business Name): MARY J BAYNE 1002817 NCCPA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VAMC 1540 SPRING VALLEY DR
HUNTINGTON WV
25704
US

IV. Provider business mailing address

3931 LEIGHWOOD DR
ASHLAND KY
41102-6711
US

V. Phone/Fax

Practice location:
  • Phone: 800-827-8244
  • Fax:
Mailing address:
  • Phone: 606-324-4677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1002817
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: