Provider Demographics
NPI:1316998347
Name:WADSWORTH, JOHN C (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:C
Last Name:WADSWORTH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 602484
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2484
Mailing Address - Country:US
Mailing Address - Phone:910-259-0400
Mailing Address - Fax:910-259-0400
Practice Address - Street 1:7910 US HIGHWAY 117 S
Practice Address - Street 2:SUITE 120
Practice Address - City:ROCKY POINT
Practice Address - State:NC
Practice Address - Zip Code:28457-7409
Practice Address - Country:US
Practice Address - Phone:910-259-0400
Practice Address - Fax:910-675-3030
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002111L363A00000X
NC0010-06043363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1316998347Medicaid
SC2533PAMedicaid
SC2533PAMedicaid
R59676Medicare UPIN
PA004098Medicare ID - Type Unspecified