Provider Demographics
NPI:1053319590
Name:IMPASTATO, JOHN P (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:IMPASTATO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 CHARLES H DIMMOCK PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2986
Mailing Address - Country:US
Mailing Address - Phone:804-526-5888
Mailing Address - Fax:804-526-5401
Practice Address - Street 1:325 CHARLES H DIMMOCK PKWY STE 100
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2986
Practice Address - Country:US
Practice Address - Phone:804-526-5888
Practice Address - Fax:804-526-5401
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06773363A00000X
OH1746363A00000X
VA0110004196363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1053319590Medicaid
OH76641Medicare PIN