Healthcare Provider Details

I. General information

NPI: 1467937854
Provider Name (Legal Business Name): JAMES ROBERT DYSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2018
Last Update Date: 10/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14010 SMOKETOWN RD # 103
WOODBRIDGE VA
22192-4722
US

IV. Provider business mailing address

88 PEACEFUL LN
LINDEN VA
22642-5144
US

V. Phone/Fax

Practice location:
  • Phone: 571-402-7322
  • Fax:
Mailing address:
  • Phone: 571-428-3002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024176656
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: