Healthcare Provider Details

I. General information

NPI: 1801085352
Provider Name (Legal Business Name): NORTHWEST ORTHOPAEDIC ASSOC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 08/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1914 W PARK DR
N WILKESBORO NC
28659-3563
US

IV. Provider business mailing address

1914 W PARK DR
N WILKESBORO NC
28659-3563
US

V. Phone/Fax

Practice location:
  • Phone: 336-667-5039
  • Fax: 336-667-5719
Mailing address:
  • Phone: 336-667-5039
  • Fax: 336-667-5719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number40711
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number40711
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number40711
License Number StateNC

VIII. Authorized Official

Name: SANDRA D SHEW
Title or Position: REGISTERED MEDICAL ASSISTANT
Credential: RMA
Phone: 336-667-5039