1457458895 NPI number — MR. ROGER LEE TALBOT SR. PHYSICIAN ASSISTANT

Table of content: MR. ROGER LEE TALBOT SR. PHYSICIAN ASSISTANT (NPI 1457458895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457458895 NPI number — MR. ROGER LEE TALBOT SR. PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TALBOT
Provider First Name:
ROGER
Provider Middle Name:
LEE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457458895
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2800 GODWIN BLVD
Provider Second Line Business Mailing Address:
STE 210
Provider Business Mailing Address City Name:
SUFFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23434-8038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-934-4162
Provider Business Mailing Address Fax Number:
757-934-4246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3920 A BRIDGE RD
Provider Second Line Business Practice Location Address:
SENTARA OCCUPATIONAL MEDICINE BELLEHARBOUR
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-983-0080
Provider Business Practice Location Address Fax Number:
757-983-0019
Provider Enumeration Date:
09/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  1029961 NCCPA , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)