Provider Demographics
NPI:1407107386
Name:DIAL, RENEE WINSTON (PA)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:WINSTON
Last Name:DIAL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:RENEE
Other - Middle Name:WINSTON
Other - Last Name:DIAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:11803 JEFFERSON AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4390
Mailing Address - Country:US
Mailing Address - Phone:757-594-1803
Mailing Address - Fax:
Practice Address - Street 1:11803 JEFFERSON AVE STE 140
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4390
Practice Address - Country:US
Practice Address - Phone:757-594-1803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003953363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical