Basic Information
| Provider Information | |||||||||
| NPI: | 1225061294 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RENICK | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | HC 68 BOX 7 | ||||||||
| Address2: | |||||||||
| City: | RENICK | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249669732 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 MAPLEWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | RONCEVERTE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249701334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046471161 | ||||||||
| FaxNumber: | 3046473006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | DO-154 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00135101 | 01 | WV | RAILROAD MEDICARE | OTHER | 23/49/50 | 01 | WV | MTST BCBS | OTHER |