Healthcare Provider Details

I. General information

NPI: 1700297207
Provider Name (Legal Business Name): RICKY MCDANIELS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

697 MADISON AVENUE
MADISON WV
25130
US

IV. Provider business mailing address

701 MADISON AVE
MADISON WV
25130-1699
US

V. Phone/Fax

Practice location:
  • Phone: 304-369-8826
  • Fax:
Mailing address:
  • Phone: 304-369-1230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1112738
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: