Provider Demographics
NPI:1104919828
Name:PETRUNGER, LEAH D (PA-C)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:D
Last Name:PETRUNGER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HUNTER PARK
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2533
Mailing Address - Country:US
Mailing Address - Phone:304-920-5122
Mailing Address - Fax:
Practice Address - Street 1:150 MISTY LANE
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740
Practice Address - Country:US
Practice Address - Phone:304-425-4040
Practice Address - Fax:304-425-4041
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV564363A00000X
WV915363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810002620Medicaid
PEPA20621Medicare ID - Type Unspecified
P82419Medicare UPIN
VA190001377Medicaid