Healthcare Provider Details

I. General information

NPI: 1346468238
Provider Name (Legal Business Name): LARRY PAYTON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD NAVAL HOSPITAL
CAMP LEJEUNE NC
28547-2538
US

IV. Provider business mailing address

100 BREWSTER BLVD NAVAL HOSPITAL
CAMP LEJEUNE NC
28547-2538
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-3905
  • Fax: 910-450-4558
Mailing address:
  • Phone: 910-450-3905
  • Fax: 910-450-4558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number269
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00250100
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000177-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: