Healthcare Provider Details

I. General information

NPI: 1043477987
Provider Name (Legal Business Name): JAMIE BETH CAROSI PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 12TH STREET EXT
PRINCETON WV
24740-2300
US

IV. Provider business mailing address

PO BOX 1030
PRINCETON WV
24740-1030
US

V. Phone/Fax

Practice location:
  • Phone: 304-431-9998
  • Fax: 304-425-0782
Mailing address:
  • Phone: 304-431-9998
  • Fax: 304-425-0782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number432
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: