Healthcare Provider Details

I. General information

NPI: 1801343231
Provider Name (Legal Business Name): CHRISTOPHER DENEAULT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 KNOTBREAK RD
SALEM VA
24153-5404
US

IV. Provider business mailing address

PO BOX 8310
ROANOKE VA
24014-0310
US

V. Phone/Fax

Practice location:
  • Phone: 540-444-4020
  • Fax: 540-444-4021
Mailing address:
  • Phone: 540-345-3556
  • Fax: 540-342-2193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110005512
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: