Basic Information
| Provider Information | |||||||||
| NPI: | 1619059177 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STRUCKMAN | ||||||||
| FirstName: | JONI | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALKER | ||||||||
| OtherFirstName: | JONI | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 337 | ||||||||
| Address2: | |||||||||
| City: | SCARBRO | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044651378 | ||||||||
| FaxNumber: | 3044692981 | ||||||||
| Practice Location | |||||||||
| Address1: | 850 INDEPENDENCE ROAD | ||||||||
| Address2: | |||||||||
| City: | COAL CITY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 258231595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044692905 | ||||||||
| FaxNumber: | 3046836906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 05/18/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 01260 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 454 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 3810007575 | 05 | WV | MEDICAID |