Healthcare Provider Details

I. General information

NPI: 1780398180
Provider Name (Legal Business Name): JACK JOSEPH POYLE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2023
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7210 VILLAGE MEDICAL CIR STE 110
CLEMMONS NC
27012-8041
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-893-2400
  • Fax: 336-893-2410
Mailing address:
  • Phone: 336-471-8153
  • Fax: 336-474-8159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-13241
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: