Healthcare Provider Details

I. General information

NPI: 1417352568
Provider Name (Legal Business Name): JOHN WILLIAM KERSHNER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2014
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWTHORNE LN BEHAVIORAL HEALTH BUILDING
CHARLOTTE NC
28204-2515
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 843-992-0216
  • Fax:
Mailing address:
  • Phone: 704-384-9414
  • Fax: 704-384-5735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number0010-05335
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-05335
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: