Provider Demographics
NPI:1093458010
Name:BUZZARD, JERRY ROY
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:ROY
Last Name:BUZZARD
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 1:332 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-1269
Mailing Address - Country:US
Mailing Address - Phone:304-757-9333
Mailing Address - Fax:866-597-0959
Practice Address - Street 1:332 6TH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1269
Practice Address - Country:US
Practice Address - Phone:304-757-9333
Practice Address - Fax:866-597-0959
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide