Provider Demographics
NPI:1528340312
Name:DONOGHUE, KAYLA ANNETTE (PA-C)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:ANNETTE
Last Name:DONOGHUE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:ANNETTE
Other - Last Name:GOUZD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:227 MEDICAL PARK DR STE 101
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9038
Mailing Address - Country:US
Mailing Address - Phone:681-342-3690
Mailing Address - Fax:
Practice Address - Street 1:165 SCOTT AVE STE 100
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-8847
Practice Address - Country:US
Practice Address - Phone:304-554-0400
Practice Address - Fax:304-554-0404
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004528363AM0700X
WV01734363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV3248AMedicare PIN