Provider Demographics
NPI:1699735779
Name:CROMWELL, STEPHEN JOSEPH (PA-C)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:JOSEPH
Last Name:CROMWELL
Suffix:
Gender:M
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 1:338 STOUT ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1426
Mailing Address - Country:US
Mailing Address - Phone:304-623-3461
Mailing Address - Fax:
Practice Address - Street 1:1 MED CENTER DR
Practice Address - Street 2:LOUIS JOHNSON V.A. MEDICAL CENTER
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-4155
Practice Address - Country:US
Practice Address - Phone:304-623-3461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00146363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant