Healthcare Provider Details

I. General information

NPI: 1083166391
Provider Name (Legal Business Name): JORGE LUIS TAPIA CEDENO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2016
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3711 ELMSLEY ST STE 101
GREENSBORO NC
27406-7039
US

IV. Provider business mailing address

300 E WENDOVER AVE
GREENSBORO NC
27401-1229
US

V. Phone/Fax

Practice location:
  • Phone: 336-890-2165
  • Fax: 336-890-2166
Mailing address:
  • Phone: 336-663-5205
  • Fax: 336-663-5366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number6022
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-15075
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: