Healthcare Provider Details

I. General information

NPI: 1801876040
Provider Name (Legal Business Name): DWAYNE BRIAN MARYOTT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2006
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 W ARLINGTON BLVD
GREENVILLE NC
27834-5704
US

IV. Provider business mailing address

1840 W ARLINGTON BLVD
GREENVILLE NC
27834-5704
US

V. Phone/Fax

Practice location:
  • Phone: 252-413-6202
  • Fax: 252-758-8333
Mailing address:
  • Phone: 252-413-6202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-01043
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA001621L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004628-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: