Healthcare Provider Details

I. General information

NPI: 1043448871
Provider Name (Legal Business Name): TINA SMITH GATEWOOD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 MAIN ST
DANVILLE VA
24541-1803
US

IV. Provider business mailing address

159 EXECUTIVE DR SUITE E
DANVILLE VA
24541-4160
US

V. Phone/Fax

Practice location:
  • Phone: 434-791-4123
  • Fax: 434-791-4126
Mailing address:
  • Phone: 434-791-2629
  • Fax: 434-791-2631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number102123
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: