Healthcare Provider Details

I. General information

NPI: 1639830714
Provider Name (Legal Business Name): DWIGHT DEADMON SA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2022
Last Update Date: 01/01/2022
Certification Date: 01/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 JOHNSTON WILLIS DR
NORTH CHESTERFIELD VA
23235-4730
US

IV. Provider business mailing address

1401 JOHNSTON WILLIS DR
NORTH CHESTERFIELD VA
23235-4730
US

V. Phone/Fax

Practice location:
  • Phone: 804-483-6111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number0136000002
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: