Basic Information
Provider Information | |||||||||
NPI: | 1639118557 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLESHER | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M-PAS PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 121 E ADAMS ST | ||||||||
Address2: |   | ||||||||
City: | PADEN CITY | ||||||||
State: | WV | ||||||||
PostalCode: | 261591309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043379146 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2121 7TH ST | ||||||||
Address2: |   | ||||||||
City: | PARKERSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 261013803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044851721 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2006 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 01084 | WV | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | MF1313282 | 01 | WV | DEA NUMBER | OTHER | 01084 | 01 | WV | PA NUMBER | OTHER | 1062799 | 01 | WV | NCC PA | OTHER |