Healthcare Provider Details

I. General information

NPI: 1740407303
Provider Name (Legal Business Name): SIR WESLEY FUNCHESS JR. PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/15/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9332 S TRYON ST
CHARLOTTE NC
28273-3108
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-587-6700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-01320
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: