Provider Demographics
NPI:1316960222
Name:RACKLEY, BOBBY DWIGHT JR (NP)
Entity type:Individual
Prefix:MR
First Name:BOBBY
Middle Name:DWIGHT
Last Name:RACKLEY
Suffix:JR
Gender:M
Credentials:NP
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Mailing Address - Street 1:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:DEPT. OF IM-INFECTIOUS DISEASE
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5051
Practice Address - Country:US
Practice Address - Phone:804-230-7742
Practice Address - Fax:804-230-8925
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024165077363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010237751Medicaid
VA010237947Medicaid