Healthcare Provider Details

I. General information

NPI: 1801230842
Provider Name (Legal Business Name): MELISA JANE SNODGRASS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2013
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6A BANK ST
NITRO WV
25143-1708
US

IV. Provider business mailing address

4605 MACCORKLE AVE SW
SOUTH CHARLESTON WV
25309-1311
US

V. Phone/Fax

Practice location:
  • Phone: 304-306-3058
  • Fax: 304-306-3059
Mailing address:
  • Phone: 304-414-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number01493
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: