Healthcare Provider Details

I. General information

NPI: 1841257508
Provider Name (Legal Business Name): ROY G. WARONSKY P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 09/01/2021
Certification Date: 09/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E STATESVILLE AVE STE 20
MOORESVILLE NC
28115-2581
US

IV. Provider business mailing address

400 E STATESVILLE AVE STE 200
MOORESVILLE NC
28115-2588
US

V. Phone/Fax

Practice location:
  • Phone: 704-360-8486
  • Fax: 704-230-4674
Mailing address:
  • Phone: 704-360-8486
  • Fax: 704-230-4674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number102512
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number102512
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: