Basic Information
Provider Information
NPI: 1003140914
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BLACK
FirstName: KARA
MiddleName: N
NamePrefix:  
NameSuffix:  
Credential: PAC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 213 MAIN ST
Address2:  
City: ELKINS
State: WV
PostalCode: 262414161
CountryCode: US
TelephoneNumber: 3046372360
FaxNumber:  
Practice Location
Address1: 213 MAIN ST
Address2:  
City: ELKINS
State: WV
PostalCode: 262414161
CountryCode: US
TelephoneNumber: 3046372360
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/24/2009
LastUpdateDate: 01/14/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000X01432WVY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

No ID Information.


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