Provider Demographics
NPI:1043288210
Name:DALTON, DOUGLAS (PA)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:DALTON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6702 TOWN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ELM CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27822-8923
Mailing Address - Country:US
Mailing Address - Phone:406-233-2500
Mailing Address - Fax:
Practice Address - Street 1:2503 FOREST HILLS RD W STE B
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3392
Practice Address - Country:US
Practice Address - Phone:252-991-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09612363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4309330OtherMDCD PIN
MT000097653OtherBCBS PIN
MT4309330OtherMDCD PIN
MT000085624Medicare PIN
MT000085623Medicare PIN
MTP00356124Medicare PIN