Basic Information
| Provider Information | |||||||||
| NPI: | 1568109627 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WARD | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | KEISHU | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6354 US ROUTE 60 E STE 4 | ||||||||
| Address2: | |||||||||
| City: | BARBOURSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255041247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047331626 | ||||||||
| FaxNumber: | 3047332012 | ||||||||
| Practice Location | |||||||||
| Address1: | 6354 US ROUTE 60 E STE 4 | ||||||||
| Address2: | |||||||||
| City: | BARBOURSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255041247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047331626 | ||||||||
| FaxNumber: | 3047332012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2022 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 00619 | WV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.