Healthcare Provider Details

I. General information

NPI: 1003290651
Provider Name (Legal Business Name): DUSTIN CRITES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2015
Last Update Date: 07/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 MACCORKLE AVE SW
SOUTH CHARLESTON WV
25309-1311
US

IV. Provider business mailing address

1431 CENTERPOINT BLVD SUITE 100
KNOXVILLE TN
37932-1984
US

V. Phone/Fax

Practice location:
  • Phone: 304-766-3601
  • Fax: 304-766-3477
Mailing address:
  • Phone: 865-539-8000
  • Fax: 865-694-5128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1901
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: