Healthcare Provider Details

I. General information

NPI: 1134574841
Provider Name (Legal Business Name): PHILIP TYLER GASTRELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2016
Last Update Date: 02/05/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 N 11TH ST
RICHMOND VA
23298-5024
US

IV. Provider business mailing address

2691 SOUTHERN HILLS CT
NORTH GARDEN VA
22959-1640
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-9350
  • Fax: 804-807-7949
Mailing address:
  • Phone: 703-405-4178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0101272771
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: