=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700824661
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOANNA B. STOVER PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2006
-----------------------------------------------------
Last Update Date | 12/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4111 1ST AVE SUITE 3
-----------------------------------------------------
City | NITRO
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25143-1345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-755-4797
-----------------------------------------------------
Fax | 304-755-4799
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4111 1ST AVE SUITE 3
-----------------------------------------------------
City | NITRO
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25143-1345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-755-4797
-----------------------------------------------------
Fax | 304-755-4799
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 01117
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------