Provider Demographics
NPI:1760900070
Name:SALTER, WILLIAM GREGORY
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:GREGORY
Last Name:SALTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 COUNTRY CIRCLE DR E
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-6658
Mailing Address - Country:US
Mailing Address - Phone:407-625-5446
Mailing Address - Fax:
Practice Address - Street 1:315 N RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32132-1617
Practice Address - Country:US
Practice Address - Phone:386-427-8403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9386867363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty