Healthcare Provider Details

I. General information

NPI: 1861714404
Provider Name (Legal Business Name): VAN AIKEN DEBLIEUX PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2010
Last Update Date: 12/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5477 MOORETOWN RD
WILLIAMSBURG VA
23188-2108
US

IV. Provider business mailing address

5477 MOORETOWN RD
WILLIAMSBURG VA
23188-2108
US

V. Phone/Fax

Practice location:
  • Phone: 757-565-0106
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number7699
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number7699
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110004783
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: