Healthcare Provider Details

I. General information

NPI: 1568465771
Provider Name (Legal Business Name): RONALD RAY SPRUILL JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 OAK LEE DRIVE
RANSON WV
25438
US

IV. Provider business mailing address

220 CAMPUS BLVD STE 100
WINCHESTER VA
22601-2896
US

V. Phone/Fax

Practice location:
  • Phone: 304-930-0001
  • Fax: 681-252-1843
Mailing address:
  • Phone: 540-536-5100
  • Fax: 540-536-0235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0002450
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110007496
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2256
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: