1790788180 NPI number — JAMES A DALTON PA-C

Table of content: JAMES A DALTON PA-C (NPI 1790788180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790788180 NPI number — JAMES A DALTON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DALTON
Provider First Name:
JAMES
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1790788180
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1573 MALLORY LN
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-2895
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-221-3855
Provider Business Mailing Address Fax Number:
615-221-1484

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1279 OLD ABBOTT MOUNTAIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESTONSBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-886-0892
Provider Business Practice Location Address Fax Number:
606-886-9746
Provider Enumeration Date:
05/31/2005

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: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA682 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 970019230 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 363A00000X , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0072290 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 95001673 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".