Provider Demographics
NPI:1124072301
Name:VECELLIO, RICHARD J (PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:VECELLIO
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:PO BOX 602148
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2148
Mailing Address - Country:US
Mailing Address - Phone:704-801-9140
Mailing Address - Fax:704-801-9141
Practice Address - Street 1:119 MARKET PLACE AVE STE D
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9157
Practice Address - Country:US
Practice Address - Phone:704-801-9140
Practice Address - Fax:704-801-9141
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102715363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1124072301Medicaid
NC970022547OtherRR MEDICARE
NCNCF666DMedicare PIN
NCNCF666FMedicare PIN
NCNCF666AMedicare PIN
NC2751522AMedicare PIN
NC970022547OtherRR MEDICARE
NCNCF6660386Medicare PIN
S78695Medicare UPIN
NC1124072301Medicaid
NCNCF666CMedicare PIN