=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548867997
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEAN PATRICK MARSHALL RILEY NURSE PRACTITIONER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2020
-----------------------------------------------------
Last Update Date | 09/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10003 WEBSTER RD
-----------------------------------------------------
City | CAMDEN ON GAULEY
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26208-7713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-226-5725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 99 CRACKER BARREL DR STE 100
-----------------------------------------------------
City | BARBOURSVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25504-1650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-525-7851
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 104996
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------