Healthcare Provider Details

I. General information

NPI: 1962865139
Provider Name (Legal Business Name): JOSHUA STORM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 04/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 WADSWORTH DR
NORTH CHESTERFIELD VA
23236
US

IV. Provider business mailing address

201 WADSWORTH DR
NORTH CHESTERFIELD VA
23236-4510
US

V. Phone/Fax

Practice location:
  • Phone: 804-285-8206
  • Fax:
Mailing address:
  • Phone: 804-285-8206
  • Fax: 804-320-3102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number01110005300
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110-005300
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: