1952490013 NPI number — MR. JAMES JOSEPH PAVAO PA-C

Table of content: MR. JAMES JOSEPH PAVAO PA-C (NPI 1952490013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952490013 NPI number — MR. JAMES JOSEPH PAVAO PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAVAO
Provider First Name:
JAMES
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
MR.
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:
1952490013
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 751649
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28275-1649
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-789-1620
Provider Business Mailing Address Fax Number:
843-724-2440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2145 HENRY TECKLENBURG DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29414-5893
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-723-8823
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2006

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: 363AS0400X , with the licence number:  1582 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: 1325 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GP5006 . This is a "MEDICAID GROUP #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: GP5005 . This is a "MEDICAID GROUP #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: GP5072 . This is a "MEDICAID GROUP #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 5551 . This is a "MEDICARE GROUP #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 0733PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP5004 . This is a "MEDICAID GROUP #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: P00648630 . This is a "RAILROAD MEDICARE ID" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: GP5007 . This is a "MEDICAID GROUP #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com