Provider Demographics
NPI:1952387748
Name:AVANCE, DAVID M (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:AVANCE
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 1:202 AGEE ST
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-2617
Mailing Address - Country:US
Mailing Address - Phone:434-392-6143
Mailing Address - Fax:434-392-3866
Practice Address - Street 1:202 AGEE ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-2617
Practice Address - Country:US
Practice Address - Phone:434-392-6143
Practice Address - Fax:434-392-3866
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840639363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
203639329OtherTRICARE PROVIDER NUMBER
10002776POtherSENTARA/OPTIMA PROVIDER N
VA010223067Medicaid
00W856C48Medicare PIN
203639329OtherTRICARE PROVIDER NUMBER