Provider Demographics
NPI:1083332837
Name:RODEHEAVER, CHAZ
Entity type:Individual
Prefix:
First Name:CHAZ
Middle Name:
Last Name:RODEHEAVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 780
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0780
Mailing Address - Country:US
Mailing Address - Phone:681-342-2133
Mailing Address - Fax:
Practice Address - Street 1:309 MEDICAL CT
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2843
Practice Address - Country:US
Practice Address - Phone:304-598-4835
Practice Address - Fax:304-598-6873
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2904363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant