Healthcare Provider Details

I. General information

NPI: 1528340312
Provider Name (Legal Business Name): KAYLA ANNETTE DONOGHUE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAYLA ANNETTE GOUZD PA-C

II. Dates (important events)

Enumeration Date: 09/16/2011
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 SCOTT AVE STE 100
MORGANTOWN WV
26508-8847
US

IV. Provider business mailing address

227 MEDICAL PARK DR STE 101
BRIDGEPORT WV
26330-9038
US

V. Phone/Fax

Practice location:
  • Phone: 304-554-0400
  • Fax: 304-554-0404
Mailing address:
  • Phone: 681-342-3690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number01734
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0004528
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: