Healthcare Provider Details

I. General information

NPI: 1639614852
Provider Name (Legal Business Name): GREGORY BULL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2016
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 RIVERSIDE CIR
ROANOKE VA
24016-4955
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 540-224-5170
  • Fax: 540-985-9427
Mailing address:
  • Phone: 540-224-5715
  • Fax: 540-224-5684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110005617
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: