Provider Demographics
NPI:1992745400
Name:GARRETT, JONATHAN DOUGLAS (PA-C)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DOUGLAS
Last Name:GARRETT
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 1845
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-1845
Mailing Address - Country:US
Mailing Address - Phone:704-873-4277
Mailing Address - Fax:704-873-4511
Practice Address - Street 1:633 BROOKDALE DR STE 300
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3471
Practice Address - Country:US
Practice Address - Phone:704-873-3250
Practice Address - Fax:704-873-2940
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103930363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
2759387Medicare ID - Type Unspecified
P00072904Medicare PIN
P44244Medicare UPIN