Provider Demographics
NPI:1972930014
Name:MEADOWS, MISTY LEE (PA-C)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:LEE
Last Name:MEADOWS
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 1:200 12TH STREET EXT
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2329
Mailing Address - Country:US
Mailing Address - Phone:304-425-9541
Mailing Address - Fax:304-425-1332
Practice Address - Street 1:200 12TH STREET EXT
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2329
Practice Address - Country:US
Practice Address - Phone:304-425-9541
Practice Address - Fax:304-425-1332
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01752363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005489001Medicaid
WV0005489002Medicaid