Healthcare Provider Details

I. General information

NPI: 1801824784
Provider Name (Legal Business Name): RICHARD LEE WAYNE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 WHITE OWL LN
CASHIERS NC
28717-4514
US

IV. Provider business mailing address

PO BOX 602373
CHARLOTTE NC
28260-2373
US

V. Phone/Fax

Practice location:
  • Phone: 828-743-2491
  • Fax: 828-743-3060
Mailing address:
  • Phone: 828-526-1280
  • Fax: 828-526-1285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number102994
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number102994
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: