Healthcare Provider Details

I. General information

NPI: 1972609550
Provider Name (Legal Business Name): ANTHONY B KNELL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 POPLAR ST STE 301
SOUTH CHARLESTON WV
25309-1473
US

IV. Provider business mailing address

500 POPLAR ST STE 301
SOUTH CHARLESTON WV
25309-1473
US

V. Phone/Fax

Practice location:
  • Phone: 304-768-4567
  • Fax:
Mailing address:
  • Phone: 304-768-4567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number376-T
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: