Provider Demographics
NPI:1174547442
Name:PERDUE, DAVID W JR (PA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:PERDUE
Suffix:JR
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 1:122 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2312
Mailing Address - Country:US
Mailing Address - Phone:304-487-7726
Mailing Address - Fax:304-431-5263
Practice Address - Street 1:122 12TH ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2312
Practice Address - Country:US
Practice Address - Phone:304-487-7726
Practice Address - Fax:304-431-5263
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV295363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001836147OtherBLUE CROSS BLUE SHIELD
VA010381096Medicaid
1070558OtherBRICKSTREET
WV3810014308Medicaid
VA010381096Medicaid
PEPA27341Medicare PIN