Provider Demographics
NPI:1477224095
Name:DALTON, ANTHONY RAY (PA-C)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:RAY
Last Name:DALTON
Suffix:
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 1:1628 BALTUSROL LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-9005
Mailing Address - Country:US
Mailing Address - Phone:503-828-6425
Mailing Address - Fax:
Practice Address - Street 1:851 LEONARD FULGHUM DR STE 100
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3793
Practice Address - Country:US
Practice Address - Phone:888-853-1529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPA3734363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPA2008OtherPA LICENSE
SCPA3734OtherPA LICENSE