Healthcare Provider Details

I. General information

NPI: 1710636055
Provider Name (Legal Business Name): JOSHUA LEE GWINN STATE CERTIFIED PRSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 WELLNESS DR
SUMMERSVILLE WV
26651-5402
US

IV. Provider business mailing address

802 OAK ST
KENOVA WV
25530-1519
US

V. Phone/Fax

Practice location:
  • Phone: 888-736-3229
  • Fax: 304-872-5415
Mailing address:
  • Phone: 304-908-1056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number21-968
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: