Provider Demographics
NPI:1245959287
Name:ADVANTAGE PRIMARY CARE
Entity type:Organization
Organization Name:ADVANTAGE PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:DETRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-381-6252
Mailing Address - Street 1:7605 FOREST AVE STE 412
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-4941
Mailing Address - Country:US
Mailing Address - Phone:804-381-6252
Mailing Address - Fax:
Practice Address - Street 1:7605 FOREST AVE STE 412
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-4941
Practice Address - Country:US
Practice Address - Phone:804-381-6252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty