Healthcare Provider Details

I. General information

NPI: 1124072301
Provider Name (Legal Business Name): RICHARD J VECELLIO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 MARKET PLACE AVE STE D
MOORESVILLE NC
28117-9157
US

IV. Provider business mailing address

PO BOX 602148
CHARLOTTE NC
28260-2148
US

V. Phone/Fax

Practice location:
  • Phone: 704-801-9140
  • Fax: 704-801-9141
Mailing address:
  • Phone: 704-801-9140
  • Fax: 704-801-9141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number102715
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number102715
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: