Healthcare Provider Details

I. General information

NPI: 1083332837
Provider Name (Legal Business Name): CHAZ RODEHEAVER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2022
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 MEDICAL CT
MARTINSBURG WV
25401-2843
US

IV. Provider business mailing address

PO BOX 780
MORGANTOWN WV
26507-0780
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-4835
  • Fax: 304-598-6873
Mailing address:
  • Phone: 681-342-2133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2904
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: