Basic Information
| Provider Information | |||||||||
| NPI: | 1174547442 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERDUE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 12TH ST | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044877726 | ||||||||
| FaxNumber: | 3044315263 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 12TH ST | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044877726 | ||||||||
| FaxNumber: | 3044315263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 08/28/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 295 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 001836147 | 01 | WV | BLUE CROSS BLUE SHIELD | OTHER | 010381096 | 05 | VA | MEDICAID | 1070558 | 01 | BRICKSTREET | OTHER | 3810014308 | 05 | WV | MEDICAID |