1720083785 NPI number — CLYDE W WOODYARD PA-C

Table of content: CLYDE W WOODYARD PA-C (NPI 1720083785)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720083785 NPI number — CLYDE W WOODYARD PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOODYARD
Provider First Name:
CLYDE
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720083785
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 21435
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24018-0551
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-772-4448
Provider Business Mailing Address Fax Number:
540-772-0410

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2726 ELECTRIC RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24018-3528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-772-4448
Provider Business Practice Location Address Fax Number:
540-772-0410
Provider Enumeration Date:
06/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  0110840258 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 242488 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 541839718 . This is a "C&O" identifier . This identifiers is of the category "OTHER".
  • Identifier: 54183971800 . This is a "WV MEDICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 200026 . This is a "LUNG" identifier . This identifiers is of the category "OTHER".
  • Identifier: 006404995 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 541839718042 . This is a "BS MOUNTAIN STATE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 541839718043 . This is a "BS MOUNTAIN STATE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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