MEDICARE: POLICARPO RODNEY DESPAIGNE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	102548	NC

General Provider Information

NPI Number	:	1063480598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	POLICARPO RODNEY DESPAIGNE PA-C

Provider Business Mailing Address
First Line	:	796 JACKEYS CREEK LN SE
Second Line	:
City	:	LELAND
State	:	NC
Zip	:	28451-9204
Country	:	US
Telephone Number	:	910-371-1980
Fax Number	:

Provider Business Practice Location Address
First Line	:	1135 MILITARY CUTOFF RD
Second Line	:	SUITE 103
City	:	WILMINGTON
State	:	NC
Zip	:	28405-3966
Country	:	US
Telephone Number	:	910-256-6222
Fax Number	:	910-256-0011

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2006
Last Update Date	:	02/29/2008

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