Provider Demographics
NPI:1417904848
Name:SMALLRIDGE, JUSTIN DAVID (CRNA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DAVID
Last Name:SMALLRIDGE
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 HOSPITAL PLZ
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WV
Mailing Address - Zip Code:26452-8558
Mailing Address - Country:US
Mailing Address - Phone:304-269-8000
Mailing Address - Fax:304-269-8090
Practice Address - Street 1:230 HOSPITAL PLZ
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-8558
Practice Address - Country:US
Practice Address - Phone:304-269-8000
Practice Address - Fax:304-269-8090
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN58541367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0207026000OtherMEDICAID GROUP
WV1417904848OtherMT STATE BLUE CROSS & BLUE SHIELD
WV3810005046Medicaid
WVP00974070OtherMEDICARE RAILROAD
WV9333201OtherMEDICARE GROUP
WVP00974070OtherMEDICARE RAILROAD
WVP00974070OtherMEDICARE RAILROAD