Basic Information
| Provider Information | |||||||||
| NPI: | 1750363685 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIPTON | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7400 LYNN AVE | ||||||||
| Address2: | |||||||||
| City: | HAMLIN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255231138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048245806 | ||||||||
| FaxNumber: | 3048245885 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 E MCDONALD AVE | ||||||||
| Address2: | |||||||||
| City: | MAN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 256351012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045838585 | ||||||||
| FaxNumber: | 3045830129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 07/10/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 342 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 969 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 3810025955 | 05 | WV | MEDICAID |