Healthcare Provider Details

I. General information

NPI: 1255300109
Provider Name (Legal Business Name): DOUGLAS DAVID DALTON II PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 CAMPUS DR SUITE 100
ABINGDON VA
24210-9700
US

IV. Provider business mailing address

603 CAMPUS DR SUITE 100
ABINGDON VA
24210-9700
US

V. Phone/Fax

Practice location:
  • Phone: 276-739-8010
  • Fax: 276-628-1410
Mailing address:
  • Phone: 276-739-8010
  • Fax: 276-628-1410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110001236
License Number StateVI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: