Provider Demographics
NPI:1679742233
Name:GWINN, JAMES CARL (PTA)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:CARL
Last Name:GWINN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 C AND O DAM RD
Mailing Address - Street 2:
Mailing Address - City:DANIELS
Mailing Address - State:WV
Mailing Address - Zip Code:25832-9653
Mailing Address - Country:US
Mailing Address - Phone:304-673-4137
Mailing Address - Fax:
Practice Address - Street 1:1777 C AND O DAM RD
Practice Address - Street 2:
Practice Address - City:DANIELS
Practice Address - State:WV
Practice Address - Zip Code:25832-9653
Practice Address - Country:US
Practice Address - Phone:304-673-4137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-27
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPTA001363225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant