Provider Demographics
NPI:1255300109
Name:DALTON, DOUGLAS DAVID II (PA-C)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:DAVID
Last Name:DALTON
Suffix:II
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 CAMPUS DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-9700
Mailing Address - Country:US
Mailing Address - Phone:276-739-8010
Mailing Address - Fax:276-628-1410
Practice Address - Street 1:603 CAMPUS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-9700
Practice Address - Country:US
Practice Address - Phone:276-739-8010
Practice Address - Fax:276-628-1410
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI0110001236363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ008299Medicaid
VA1255300109Medicaid
VAC10529Medicare UPIN
VAVV6973AMedicare PIN
VA1255300109Medicaid
VAVV6973BMedicare PIN