Healthcare Provider Details

I. General information

NPI: 1760751952
Provider Name (Legal Business Name): GINA MARIE CARENBAUER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
MORGANTOWN WV
26506-1200
US

IV. Provider business mailing address

6715 MANORLY CT
FREDERICK MD
21703-2859
US

V. Phone/Fax

Practice location:
  • Phone: 559-882-2738
  • Fax:
Mailing address:
  • Phone: 412-651-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA030799
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA030799
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2589
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: