Individual
KIESHA MARIE BULLOUGH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
700 OAKMOUND RD, CLARKSBURG, WV 26301-9398
(304) 623-6330
(304) 623-6220
Mailing address
700 OAKMOUND RD, CLARKSBURG, WV 26301-9398
(304) 623-6330
(304) 623-6220
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
01444
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3810016314
—
WV
Enumeration date
11/17/2009
Last updated
06/17/2016
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