Healthcare Provider Details

I. General information

NPI: 1982979464
Provider Name (Legal Business Name): IGNATIUS HALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2012
Last Update Date: 03/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 RIVER RD
PETERSBURG VA
23834
US

IV. Provider business mailing address

1090 RIVER RD
PETERSBURG VA
23834
US

V. Phone/Fax

Practice location:
  • Phone: 804-504-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA002932L
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: