Healthcare Provider Details

I. General information

NPI: 1467632505
Provider Name (Legal Business Name): JOHN TIMOTHY RUNNION PA.C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 KANAWHA AVE
RAINELLE WV
25962-1013
US

IV. Provider business mailing address

645 KANAWHA AVE
RAINELLE WV
25962-1013
US

V. Phone/Fax

Practice location:
  • Phone: 304-438-6188
  • Fax: 304-438-6819
Mailing address:
  • Phone: 304-438-6188
  • Fax: 304-438-6819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number909
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number249
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: