Healthcare Provider Details

I. General information

NPI: 1649702358
Provider Name (Legal Business Name): RONALD PRYOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 AUBREYS LOOP
SOUTH BOSTON VA
24592-5054
US

IV. Provider business mailing address

101 AUBREYS LOOP
SOUTH BOSTON VA
24592-5054
US

V. Phone/Fax

Practice location:
  • Phone: 434-517-3788
  • Fax: 434-517-3989
Mailing address:
  • Phone: 434-517-3788
  • Fax: 434-517-3989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0017143823
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: