Healthcare Provider Details

I. General information

NPI: 1255836318
Provider Name (Legal Business Name): JAMIE VICTORIA MUCCIOLI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
MORGANTOWN WV
26506-1200
US

IV. Provider business mailing address

PO BOX 780
MORGANTOWN WV
26507-0780
US

V. Phone/Fax

Practice location:
  • Phone: 855-988-2273
  • Fax:
Mailing address:
  • Phone: 681-342-2133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2935
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT007272
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: