Healthcare Provider Details

I. General information

NPI: 1053879502
Provider Name (Legal Business Name): DYLAN THOMAS PLOCKI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2019
Last Update Date: 03/09/2025
Certification Date: 03/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 NORTHLINE AVE STE 200
GREENSBORO NC
27408-7602
US

IV. Provider business mailing address

3200 NORTHLINE AVE STE 200
GREENSBORO NC
27408-7602
US

V. Phone/Fax

Practice location:
  • Phone: 336-545-5000
  • Fax: 336-545-5020
Mailing address:
  • Phone: 336-545-5000
  • Fax: 336-545-5020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-08998
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: