Provider Demographics
NPI:1427087261
Name:ROYSTON, DWIGHT (PA)
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:
Last Name:ROYSTON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 KIRMAN AVE
Mailing Address - Street 2:AMBULATORY CARE SERVICE (11AC)
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-0993
Mailing Address - Country:US
Mailing Address - Phone:805-698-7417
Mailing Address - Fax:
Practice Address - Street 1:975 KIRMAN AVE
Practice Address - Street 2:AMBULATORY CARE SERVICE (11AC)
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-0993
Practice Address - Country:US
Practice Address - Phone:805-698-7417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15817363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA15817BMedicare ID - Type UnspecifiedLANCASTER #