Healthcare Provider Details

I. General information

NPI: 1568438539
Provider Name (Legal Business Name): LARRY R GITELMAN ADVANCED RN PRACT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 AMERICAN WAY STE A
WEIRTON WV
26062-4083
US

IV. Provider business mailing address

PO BOX 6230
WHEELING WV
26003-0722
US

V. Phone/Fax

Practice location:
  • Phone: 304-797-6410
  • Fax: 304-797-6320
Mailing address:
  • Phone: 304-242-7106
  • Fax: 304-242-7108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberVP005783L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN59184
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: