Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP2300X | Nurse Practitioner - Primary Care | 105016 | WV |
NPI | 1083250963 |
---|---|
Provider Name | Tanya Ann Maddy |
First Address | Oak Hill, WV 25901-3439 |
Second Address | Beckley, WV 25801-3397 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/11/2019 |
Last Update Date | 26/11/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
AG11190009 | AANP (01) | WV |