MEDICARE: DOUGLAS DALTON PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0010-09612	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4309330	OTHER	MT	MDCD PIN
2	000097653	OTHER	MT	BCBS PIN

General Provider Information

NPI Number	:	1043288210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS DALTON PA

Provider Business Mailing Address
First Line	:	6702 TOWN CREEK RD
Second Line	:
City	:	ELM CITY
State	:	NC
Zip	:	27822-8923
Country	:	US
Telephone Number	:	406-233-2500
Fax Number	:

Provider Business Practice Location Address
First Line	:	2503 FOREST HILLS RD W STE B
Second Line	:
City	:	WILSON
State	:	NC
Zip	:	27893-3392
Country	:	US
Telephone Number	:	252-991-0555
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	01/25/2022

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Directions to “ DOUGLAS DALTON PA” Practice Location

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