Provider Demographics
NPI:1043049828
Name:FANCY GAP INTERNAL MEDICINE
Entity type:Organization
Organization Name:FANCY GAP INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:TRACY
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:276-728-0735
Mailing Address - Street 1:1661 TURNER SPUR RD
Mailing Address - Street 2:
Mailing Address - City:FANCY GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24328-4365
Mailing Address - Country:US
Mailing Address - Phone:276-728-0735
Mailing Address - Fax:866-464-0644
Practice Address - Street 1:1661 TURNER SPUR RD
Practice Address - Street 2:
Practice Address - City:FANCY GAP
Practice Address - State:VA
Practice Address - Zip Code:24328-4365
Practice Address - Country:US
Practice Address - Phone:276-728-0735
Practice Address - Fax:866-464-0644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty